Background : Two ischemic stroke with rare infective causes with clinical suspicion highlighted.
Results :
Case 1 is a 47 year old lady was admitted for subacute onset of headache, photophobia and diplopia on right side gaze. There was right sixth nerve palsy , with no lateralizing sign nor fever in clinical assessment. Complete blood count showed raised WCC and blood culture grew Gemella morbillorum. Lumbar puncture showed normal opening pressure with leucocytosis.Despite systemic anti-microbiological therapy, she developed right internal carotid artery occlusion with enlarging middle cerebral artery infarct. as evident in serial CT brain and CT angiogram of neck and head vessels. CT venogram of brain revealed filling defect in both cavernous sinus, more severe on right side and compatible with dural venous thrombosis. The overall diagnosis was cavernous sinus thrombophlebitis, secondary ICA occlusion and CNS angitis. Thorough search for infective ethology, including dental and ENT assessment, cardiac echo and HIV serology were all negative.
Case 2 is a 71 year old man was admitted the second time for right side headache and decreased general condition. Two week ago, he was admitted for first unprovoked seizure and sputum was saved for TB and smear negative. Day 7 after second admission he developed right cerebral infarct and decreased sensorium. Sputum culture from negative smear sample finally grew M. tuberuculosis. Lumbar puncture was then performed and revealed findings suggestive of tuberculous meningitis. Dexamethasone and anti TB therapy was initiated with gradual clinical improvement seen. MRI brain also showed basal leptomeningeal changes.