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Papilloedema and lymphocytic meningitis in a 68 year old man.

Received 15 August 1994. Accepted 2 September 1994 Case presentation This 68 year old man presented in late February 1992 with a one month history of intermittent blurring of vision, lasting seconds, in the right eye. He also had mild intermittent occipital headache, mostly at night, with some nausea in the morning. He had noticed some hearing loss in the left ear with tinnitus for about a year, and his wife thought he was a little unsteady on his feet. He was a diabetic controlled on diet, and there had been some recent weight loss. In earlier years he had been a heavy drinker, but no longer. He had never smoked. He was known to be in atrial fibrillation and had previously had a myocardial infarction. Many years ago there had been a "shadow on the lung", possibly tuberculosis. On examination he was in atrial fibrillation but there were no other general medical abnormalities; his chest and abdomen were normal; there was no lymphadenopathy. There was bilateral papilloedema much more on the right than the left but he had normal visual acuities. There was mild sensorineural deafness, more on the left than the right. There were some slight cerebellar signs on the left, his reflexes were brisk but symmetric, and the plantar responses were flexor. Computed tomography (fig 1) was reported as normal, although there was concern about aqueduct stenosis. He was polycythaemic (haemoglobin 180 g/l and packed cell volume 54%). The other blood indices were normal, and the erythrocyte sedimentation rate was 2 mm/h. Numerous other investigations were done at that point and over the next few weeks and were normal. These included urea, electrolytes, liver function, proteins and protein electrophoresis, calcium, alkaline phosphatase, B12, folate, serum iron, coagulation screen, antinuclear factor, rheumatoid factor, anticardiolipin antibodies, lupus anticoagulant, creatine kinase, calcium, and chest radiograph. His ECG showed atrial fibrillation. Because of the possibility of aqueduct stenosis a right parietal access device was inserted and the intracranial pressure peaked at 30-40 cm H2O. The protein concentration in the CSF was normal (0 3 g/l), but there were 46 white blood cells/,ul (90% lymphocytes). The CSF glucose concentration was 7-1 mmol/l with a blood glucose concentration of 12A4 mmol/l. No organisms were seen on Gram stain, no acid fast bacilli were seen,