JOURNAL ARTICLE

A 46-Year-Old With Persistent Altered Mental Status and Respiratory Failure

Ann F Yang, Aesha Jobanputra, Thomas J Kirn, et al 

Clinical Infectious Diseases, Volume 82, Issue 1, 15 January 2026, Pages 159–161, https://doi.org/10.1093/cid/ciaf439

Question:

A 46-year-old undomiciled man with a past medical history of alcohol use disorder was found unresponsive and admitted for evaluation of altered mental status. He immigrated from Mexico in 1991 and lived in Florida for several years as a gardener.

On presentation, he exhibited emesis, agitation, tachycardia, hypertension, and a fever of 102.9 F. Tremors and tongue fasciculations were noted on physical exam. Bilateral lower lobe consolidations consistent with aspiration were noted on CT chest with negative SARS-CoV-2 PCR results. The patient was briefly intubated for airway protection and treated with empiric piperacillin/tazobactam for aspiration pneumonia and benzodiazepines for alcohol withdrawal, with improvement in mental status and pulmonary infiltrates.

On hospital day 6, a repeat SARS-CoV-2 test was done due to persistent fevers and returned positive. On hospital day 7, the patient was found to have unequal pupillary response. Repeat CT head imaging showed a new left superior cerebellar artery (SCA) infarct, along with subarachnoid and intraventricular hemorrhages. The neurosurgical team was consulted and recommended no surgical interventions. On hospital day 8, the patient required supplemental oxygen with nasal cannula and was started on dexamethasone 6 mg/day and remdesivir. On hospital day 10, digital subtraction angiography of the brain demonstrated findings consistent with vasospasms, and nimodipine therapy was initiated. The patient remained hospitalized for waxing/waning mental status.

On hospital day 15, the patient was re-intubated due to progressively worsening acute hypoxemic respiratory failure and was found to have new nodular opacity in the right upper lobe and new bilateral tree-in-bud opacities involving all lobes. Subsequently, the patient underwent bedside bronchoscopy, which demonstrated these findings on the cell culture dish (Figure 1) and gram stain (Figure 2) of the bronchoalveolar lavage (BAL). The patient remained persistently comatose with a Glasgow Coma Score of 2T despite being off sedation and a relatively benign MRI of the brain and EEG. Of note, the patient's absolute eosinophil count increased from 20 cells/µL on admission, with a peak eosinophil count at 920 cells/µL on hospital day 40. Lumbar puncture revealed cerebrospinal fluid (CSF) with a total white blood cell count of 237 cells/µL, predominantly neutrophils (192 cells/µL), and a lymphocyte count of 28 cells/µL. The red blood cell count was elevated at 2915 cells/µL. Cerebrospinal fluid glucose was decreased at 38 mg/dL (reference range: 40–80 mg/dL), and protein was markedly elevated at > 600 mg/dL (reference range: 15–45 mg/dL). A gram stain of the CSF specimen reveals these organisms with no bacterial growth on culture (Figure 3).

What is your diagnosis?