Differential Diagnosis for New Onset Refractory Temporal Seizure
- Single Most Likely Diagnosis
- Hepatic Encephalopathy with Seizure: The patient's history of cirrhosis and new onset refractory temporal seizure, along with elevated RBC, WBC, and protein in CSF, could suggest a complication of hepatic encephalopathy, which can sometimes present with seizures. The temporal hyperintensity on MRI might be related to the seizure activity itself or to a specific complication of hepatic encephalopathy affecting the brain.
- Other Likely Diagnoses
- Autoimmune Encephalitis: Given the temporal lobe involvement (suggested by the temporal seizure and hyperintensity on MRI) and the presence of inflammatory markers in the CSF (elevated WBC and protein), autoimmune encephalitis is a plausible diagnosis. The absence of HSV in the CSF does not rule out other forms of autoimmune encephalitis.
- Bacterial or Fungal Meningitis: Although the patient has cirrhosis, which might predispose to certain infections, the absence of specific bacterial or fungal markers in the CSF provided does not strongly support this diagnosis. However, given the elevated WBC and protein in CSF, it remains a consideration, especially if the patient shows signs of infection.
- Do Not Miss Diagnoses
- Central Nervous System (CNS) Vasculitis: This condition can present with seizures, inflammatory changes in the CSF, and abnormalities on MRI. It is crucial to consider CNS vasculitis due to its potential for severe outcomes if left untreated.
- Cryptococcal Meningitis: Especially in immunocompromised patients or those with advanced liver disease, cryptococcal meningitis can present with similar CSF findings and requires prompt diagnosis and treatment to prevent severe morbidity and mortality.
- Rare Diagnoses
- Paraneoplastic Encephalitis: Although rare, paraneoplastic syndromes associated with various cancers can present with encephalitis, seizures, and specific MRI findings. The patient's cirrhosis might increase the risk of hepatocellular carcinoma, which could potentially be associated with paraneoplastic phenomena.
- Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes (MELAS): This is a rare mitochondrial disorder that can present with seizures, encephalopathy, and characteristic MRI findings, including hyperintensities that might resemble those seen in the temporal lobe of this patient.