A 10-year-old boy is referred to the neurologist with intellectual deterioration, personality changes, generalized seizures, and visual disturbances that have worsened over the last few months. The patient’s cerebrospinal fluid culture shows no bacterial growth. Further analysis shows normal glucose levels and normal protein.
The patient is afebrile and reports no headache. The child’s parents say that he has not received any vaccinations since arriving in the United States last year. They also say that he has had only one major illness prior to this. The child was approximately 2 years old when he developed a high fever, cough, and runny nose. Soon after the onset of these symptoms, he developed a red maculopapular rash that spread downward from his head.
Antibodies against which of the following are likely to be found in this patient’s cerebrospinal fluid?
A. Herpes simplex virus type 2 B. Measles virus C. Mumps virus D. Neisseria meningitidis E. Rubella virus F. Treponema pallidum
Measles virus-the correct answer is b. this patient is most likely suffering from subacute sclerosing panencephalitis. this is a rare progressive demyelinating disease associated with chronic central nervous system infection with measles virus. there is often a history of primary measles infection at an early age (approximately 2 years) followed by a latent interval of 68 years. initial manifestations include poor school performance and mood and personality changes. fever and headache do not occur. as the disease progresses, patients develop progressive intellectual deterioration, focal and/or generalized seizures, myoclonus, ataxia, and visual disturbances. the cerebrospinal fluid (csf) is acellular with normal or mildly elevated protein and markedly elevated gamma globulin (>20% of total csf protein). csf anti-measles antibodies are elevated. ct and mri show evidence of multifocal white matter lesions, cortical atrophy, and ventricular enlargement.answer a is incorrect. herpes simplex virus 2 (hsv-2) can cause a recurrent meningitis. as with the other examples, one would expect to see signs of meningeal irritation as well as an increase in lymphocytes. infection with hsv-2 is often associated with genital lesions.answer c is incorrect. the patient has no evidence of current mumps infection. mumps virus can cause acute viral meningitis, but one would expect to see classic signs of meningitis as well as an increase in lymphocytes in the cerebrospinal fluid.answer d is incorrect. neisseria meningitidis can cause bacterial meningitis. these organisms would likely be discovered on culture of the csf. bacterial meningitis would also manifest in a high fever with meningeal signs (headache, nuchal rigidity) as well as decreased csf glucose, increased csf protein, and mononuclear and/or polymorphonuclear cells.answer e is incorrect. rubella virus causes german measles, which is generally characterized by fever and upper respiratory symptoms that resolve with subsequent rash. the maculopapular rash usually starts with the face and descends to the extremities, lasting only several days.answer f is incorrect. infection with treponema pallidum can eventually lead to neurosyphilis, which can include some of the symptoms described in this case. the patient has neither elevated csf protein nor the presence of mononuclear cells. there is also little evidence in the history of prior or current infection with t. pallidum.