This male patient presented at the age of 27 with recurrent chest infections and weight loss. Two years later a diagnosis of cortical thymoma (type B2) was made and he underwent a successful surgical excision. Post-operatively he continued to have multiple infections, mainly pneumonias, and investigations revealed low serum immunoglobulins (Supplementary Table 1). He was referred to Clinical Immunology where a complete absence of peripheral B cells was identified, with minimal bronchiectasis on a thoracic CT scan. The combination of thymoma with immunodeficiency led to the diagnosis of Good’s syndrome and he was commenced on immunoglobulin replacement, with prophylactic Co-Trimoxazole, to good effect.
Lower respiratory tract infections became less frequent, but he cultured Haemophilus influenzae in his sputum twice over the subsequent years. He also had an episode of unilateral epididymo-orchitis complicated by abscess formation. Aged 31 he developed bulbar and penile urethral strictures for which he required a urethroplasty.
Aged 36 he suffered a brief episode of right hemiparesis with dysaesthesia and dysarthria. Brain MRI, CT head, echocardiogram and carotid doppler did not reveal a cause for his symptoms and these were attributed to a transient ischemic attack. Over the following years he attended the emergency department three more times for neurological symptoms of vertigo, ataxia, dizziness and/or facial dysaesthesia, with continuing normal brain imaging.
Aged 41 he presented with an episode of facial and left upper limb dysaesthesia. A CT head was normal but an MRI at that stage revealed white matter high T2 intensity suggestive of transependymal oedema. Over the next 2 months he complained of deteriorating headaches with photophobia and was found to have a mild cognitive impairment (23/30 on Montreal Cognitive Assessment test). He was later admitted to hospital with a focal seizure, left facial weakness and dysarthria. An EEG revealed abnormal asymmetrical activity in his frontal lobe, but no seizure activity. His repeat MRI revealed progression of the previously noted abnormalities, with an enlargement of the ventricular system in keeping with hydrocephalus and a rarely described pattern of T2 high intensity in the claustrum (Figure 1). A subsequent CT head confirmed communicating hydrocephalus (Figure 1) and a lumbar puncture revealed a significantly raised CSF protein (Supplementary Table 1). CSF was lymphocytic and enterovirus was identified by PCR (non-polio, non-typable). This was confirmed in two more lumbar punctures. His blood, throat and stool samples were consistently negative for enterovirus. His IgG trough on replacement immunoglobulin at that stage was good, >8g/L.
He was treated with levetiracetam and an experimental drug for enteroviral infection pocapavir (MedChemExpress LLC). His immunoglobulin dose was also increased and an external ventricular drain was inserted to relieve the hydrocephalus. An attempt to remove this led to re-accumulation of hydrocephalus so a permanent ventriculoperitoneal shunt was inserted. After a prolonged hospital stay he made a partial recovery but was unable to drive or work for several years. Currently, at the age of 46, he has managed to return to work and is able to drive but exhibits intermittent bilateral hand tremor.