4/28 H&P: HPI: Hx obatined form chart review and wife. 58 y/o male patient with history of B-cell lymphoblastic leukemia who was treated with hyper CVAD then dasatinib  s/p allogenic stem cell transplant in 2018 on remission and cGVH 5/19/2020 requiring prednisone 5 mg daily on chronic acyclovir, bactrim and fluconazole who follows up at UM with Dr., also pt with hx of hypothyroidism, hyperlipidemia and hyponatremia presented today complaining of weakness for the last 2 days and headache the day prior to admission. Pt was taking Tylenol for the headache, and per wife he had a temp of 99 F. Denies any GI, urinary or abdominal symptom. Pt was being treated for a toe infection (ingrown toenail) with clindamycin. Pt travel during the weekend for 2 days where he did not have contact with any infected person. Pt is compliant with his medications and follows for his medical care. Today at the ED pt was having headache and during the afternoon started with AMS, became agitated, with upper extremity tremors and nuchal rigidity. Ct head did not showed any acute abnormality. However, pt developed a fever. LP was performed pending results. Started on empiric treatment for meningitis: vancomycin, acyclovir and ceftriaxone. MICU was called to admit patient due to worsening of mental status. PMH: hyperlipidemia, primary hypothyroidism, hx ALL s/p bone marrow transplant and cGVH. Allergies: denies. Medications:  Acyclovir 800 mg BID, amlodipine 5 mg daily, fluconazole 200 mg BID, levothyroxine 175 mcg, pantoprazole, prednisone 5 mg daily, bactrim 1 tab 3 times a week, terbinafine cream and triamcinolone.  Social: form Miami. No hx of alcohol, smoking. Physical Exam: Nursing note and vitals reviewed. Constitutional: Vital signs are normal. Pt lethargic, disoriented, no following commands w/o respiratory distress. HENT: Head: Normocephalic and atraumatic. Eyes: Conjunctivae and EOM are normal. Neck: No JVD present. Cardiovascular: Regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. He has no rales. He exhibits no tenderness. Abdominal: Bowel sounds are normal. There is no abdominal tenderness. There is no rebound and no guarding. Lymphadenopathy:  He has no cervical adenopathy. Neurological: Disoriented. Nuchal rigidity. Resting tremors. Hyperreflexia lower extremities. No clonus. Does not follow commands. Moves 4 extremities. Skin: Skin is warm.   4/29 ID note: 58yo M patient who comes with CC of 2 days of weakness and 1 day of headache. Progressive onset and no other associated symptoms, weakness referred as generalized by wife and headache really started on day of admission. He has an important history of B-cell lymphoblastic leukemia diagnosed 03/12/2018 ( +), treated with 2 cycles of hyperCVAD, and desatinib (latter stopped on 02/22/21 due to fluid retention), on remission. s/p allogenic stem cell transplant on 08/21/18 (CMV +/+) from brother (10/10 donor), which engrafted 09/01/2018. And chronic graft vs host disease diagnosed on 05/19/20 due to scleroderma of bl upper extremities, elevated LFTs and swelling of upper and lower extremities with decreased ROM, started on steroid initially 40mg bid and eventually 5mg qd since 03/16/21 He was on prophylaxis with Acyclovir, Bactrim 1 tab 3 times a week, and Fluconazole. In the ED patient found to be initially alert and oriented, but during the day became more agitated, eventually having altered mental status and becoming non verbal. He also presented fever. On evaluation physical exam showed a patient making incoherent sounds, with tremors which stopped, increased muscle tone and some rigidity and increased reflexes, nystagmus, not following command but retracting extremities when touched or moved, with possible kernig and brudzinski signs. Started on Ceftriaxone, Vancomycin and Acyclovir and changed to Cefepime, Vancomycin, Ampicillin and Acyclovir by MICU team. Acyclovir changed to Ganciclovir by ID. CSF without pleocytosis, normal glucose and only mild elevated protein. CT and MRI without acute findings. Assessment: 58yo M patient with history of ALL in 2018 s/p Allo-SCT (CMV+/+) at UM 2018, and complicated by chronic GVHD, currently on prednisone 5mg daily and prophylaxis with Bactrim three times a week, Acyclovir and Fluconazole, who presented with headache, fever and generalized weakness for 2 days. Became encephalopathic and was admitted to MICU. 1. Meningoencephalitis in immunocompromised patient - No changes since yesterday, leukocytosis 15.22 and Tmax 100.2- Negative HIV, RPR, - Culture CSF NGTD, Blood culture negative day 1, respiratory panel negative- Repeat LP- Pending additional studies, 2. Other problems- Hypothyroidism- Hyperlipidemia- Hyponatremia- Toe infection (ingrown nail) - 01/2021- CKD II and congenital solitary kidney -Baseline Cr 1.3 Plan: - Continue Ampicillin, Cefepime, Vancomycin and Ganciclovir- In process CSF HSV 1/2, CMV, culture- Ordered serum VZV,Crypoptococcus, Fungitell, Galactomannan, West Nile IgM, CMV PCR- Ordered Quantiferon-Gold- Needs LP and CSF - Measure opening pressure, Encephalitis panel, cryptococcus, Fungal, AFB, viral  culture, HHV6 PCR, EBV DNA PCR, VZV PCR, West Nile virus, Adenovirus, NMDA- Plan for LP today, family agreed.   5/3 ICU update: Patient has been accepted at where he is well known to the heme/onc service.  Will transfer today.