Isolated CNS Whipple's disease: a diagnostic dilemma.

To cite: Kundu A, Sen P, Khurana S. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015211784 DESCRIPTION A 64-year-old diabetic Caucasian man presented with progressively worsening neurological symptoms including memory loss, involuntary teeth clenching, difficulty maintaining balance, daytime somnolence and cognitive impairment for the past 2 years. Nine months prior, CT scan of the brain had shown mild uncomplicated hydrocephalus (figure 1). The patient underwent further evaluation with a brain MRI, which demonstrated an apparent web traversing the cerebral aqueduct at its midpoint with faint associated enhancement (figure 2). The lateral and third ventricles were noted to be enlarged but unchanged compared to prior CT. The extra-axial cerebrospinal fluid (CSF) spaces were of normal size. There were periventricular hyperintensities suggestive of chronic small vessel ischaemia and/or transependymal fluid shift. CISS images showed a small web traversing the cerebral aqueduct at its midpoint with distention of the proximal half of the aqueduct in comparison to the distal half. Lumbar puncture was then performed and showed a normal CSF analysis,