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A 47 year old man presented to the emergency department of our hospital. He was born in Uruguay, but had lived in Australia for many years and had not travelled overseas recently. He had no relevant medical history or record of illicit drug use. He had a 2 week history of a coarse, postural tremor of the upper limbs and an unsteady gait and was brought to hospital after an unwitnessed fall at home. On arrival he was alert but “irritable”; shortly thereafter he had a generalised seizure, which was treated with intravenous diazepam and phenytoin. Several hours later he had failed to regain consciousness: he was breathing spontaneously, with roving eyes, absent oculocephalic reflexes, generalised hypertonia and hyperreflexia, bilateral extensor plantar responses, was afebrile, and had no neck stiffness. He was intubated for airway management and had a normal precontrast and postcontrast cerebral CT. A lumbar puncture disclosed normal CSF pressure (15 cm H2O), with a high protein (1.34 g/l) but normal cell count and glucose. Angiography of the vertebrobasilar system was normal. Intravenous heparin was started, and later intravenous acyclovir. After extubation, he had ongoing cognitive impairment and remained generally hyperreflexic with extensor plantar responses. His admission was characterised by a fluctuating, but slowly improving, delirium. He had short term memory deficits, visual and auditory …
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