Endocrine Case Report: Epigastric Pain in T2D and Hypothyroidism

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This endocrine case report from Brady Pregerson, MD, features a woman in her early 50s with a history of type 2 diabetes and hypothyroidism presenting with 5 days of epigastric pain. Can you determine the correct diagnosis?

History of Present Illness:

A woman in her early 50s with a history of type 2 diabetes and hypothyroidism presents to the emergency department for epigastric pain, vomiting, and headache for 5 days. She was seen yesterday in your ED and had belly labs and ultrasound, all of which are essentially unremarkable except for a fatty liver.

A careful history reveals that the headache was actually the first symptom and the abdominal pain isn’t that bad and only started after the vomiting. When probed she also endorses chills and photophobia. She came back because she feels that yesterday the doctor only focused on the abdominal pain and once those tests came back OK, he seemed uninterested in her other symptoms.

She appreciates you asking more questions and it also comes up that she was admitted at another hospital a little over a month ago for “fungal pneumonia,” but she can’t remember any more details about that other than that she finished the medication about 3 weeks ago.

Vital Signs & Physical Exam:

Vital signs are normal except for a BP of 161/99 and a temperature of 99.1. A physical exam is notable for initially having her head covered with a black sweater, an across-the-room clue to photophobia, and a positive jolt sign.

Initial Diagnostic Testing:

  • CBC: normal except for WBC of 9.1 with 79% PMN’s
  • Chem 7: normal except for glucose 161
  • Imaging: CT head normal. CXR normal.
  • LP: opening pressure 35 with sputtering fluid
  • CSF: glucose 30, protein 275, WBC 1,800 (50% lymphs, 15% PMNs), RBC 15

What is the most likely cause of her meningitis?