R. NICKBRYANMDPATRICIA A.HUDGINSMD
A 46-YEAR-OLD man presented with a 1-year history of a severe progressive headache and neck stiffness. He complained of fever but denied nausea or vomiting. His medical history was significant for 20 years of alcohol abuse and a previous elevation in serum bilirubin levels. His temperature was 38.3°C; heart rate, 99 beats/min; and blood pressure, 126/75 mm Hg. He was awake and oriented to person, place, time, and situation but demonstrated slow mentation. His physical examination was remarkable for rigidity and tenderness in the lateral aspect of the left side of his neck. There was no evidence of masses, lymphadenopathy, or edema. Right-sided torticollis and a mild amount of trismus were also observed. A bulging posterior nasopharynx was noted on fiberoptic examination. The findings of cranial nerve examination were normal. The white blood cell count was 13 800 cells per high-power field. A lumbar puncture disclosed the following values: 660 white blood cells; 96% polymorphonuclear neutrophils; 330 red blood cells per high-power field; glucose, less than 20 mg/dL; and protein, higher than 300 mg/dL. A gram stain revealed no organisms. A plain lateral x-ray film of the cervical spine is shown in Figure 1; an axial, non–contrast-enhanced computed tomographic (CT) scan at the level of the first cervical vertebrae (C1) is shown in Figure 2; a postgadolinium sagittal T1-weighted magnetic resonance imaging (MRI) scan with fat saturation through the midline of the patient's cervical spine is shown in Figure 3; and a postgadolinium axial T1-weighted, fat-saturated sequence MRI scan at the level of the dens is shown in Figure 4.
Boole JR, Ramsey M, Petermann G, Sniezek J. Radiology Quiz Case. Arch Otolaryngol Head Neck Surg. 2003;129(11):1247. doi:10.1001/archotol.129.11.1247