Case presentation: A 70-year-old man with end stage liver disease was presented to the ED with complaints of increasing gait disturbances over the past several weeks and new onset diplopia and blurry vision. He also had persistent headaches, body aches, and recurrent confusion. Nausea and vomiting had impaired his ability to take his prescribed lactulose.
He had been admitted to the hospital in the recent past many times, and the diagnosis was hepatic encephalopathy. Examination: His neurological examination was performed which identified a focal cranial nerve deficit, and an MRI revealed restricted diffusion, which was suspicious for small acute infarcts and revealed diffuse leptomeningeal enhancement suggestive of meningitis. Hematology findings were as follows: white blood cell count and differential within normal limits, mild chronic normocytic anemia, slightly prolonged coagulation…
