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Cough, confusion and flaccid paralysis in a 46-year old man with left apical consolidation and ring-enhancing lesions on cerebral imaging

A 46-year-old man was admitted with confusion and lower limb weakness that had developed over 2 weeks. A history of chronic productive cough was noted. Significantly, 4 years previously he had been investigated for cough and left apical lung consolidation. No evidence of Mycobacterium tuberculosis was found at the time and this was not investigated further. The only other relevant history was of heavy ethanol intake and self-neglect.

The patient was febrile (38.6°C), confused and unwell. He had evidence of finger clubbing, poor oral hygiene and signs of consolidation in the left lung. Early bilateral papilloedema and a flaccid paralysis in the lower limbs were noted. Admission investigations identified a raised white cell count of …