Radiology quiz.

A 38-year-old Bangladeshi male presented to the Emergency Room with acute confusional state for 3 days, constitutional symptoms for 3 months and testicular mass for 2 months. Clinical examination revealed that he was febrile, confused, agitated with normal cranial nerves, normal motor system with bilateral down going planters, and there were no cerebeller sign. Systemic examination showed no lymphodenopathy or abnormal breath sound, there was tender liver with firm immobile epididymal swelling. The patient was started on ceftriaxone, and computed tomography of brain was carried out with normal findings. Cerebrospinal fluid was pale yellow, 31 WBCs differential: PMN 95%, mononuclear cells 5%, protein 2.1 gm, glucose 0.8 mmol. Erythrocyte sedimentation rate 8, CBCs normal. With this clinical and CSF picture, the patient was started empirically on anti-TB medication. Repeated CSF revealed 160 WBCs, and 8 gm protein (traumatic sample). The patient showed marked improvement after 10 days of starting anti-TB drugs. Liver biopsy confirmed presence of granuloma. Epyndidymal biopsy was normal. The patient was discharged from the hospital after 20 days in stable condition. Submitted by: Dr. Fahad Al-Greeshah Senior Resident, Division of Neurology Armed Forces Hospital, Riyadh Kingdom of Saudi Arabia