Background Tuberculous pachymeningitis is a rare form of extrapulmonary tuberculosis usually suspected from the detection of thickening of the dura in contrast-enhanced magnetic resonance imaging. Progressive nature of the disease can lead to chronic headache with focal neurological signs due to compression from the thickened dura. Case Report We report a 40-year-old female who presented with chronic headache over a decade associated with recurrent neurological abnormalities including optic neuritis, hemisensory loss, migraine, facial nerve palsy, and recurrent vertigo. Although there was an initial perceived response to steroids, the patient had a subsequent progressive course. On investigations, she was found to have a diffused dural thickening on contrast MRI with a strongly positive Mantoux test with caseating necrotizing granulomatous inflammation on dural histology. With initiation of antituberculous medication with steroids, the patient markedly improved, and the medication for tuberculosis was continued for a year with good response. Conclusion Primary tuberculous pachymeningitis should be suspected in a patient complaining of prolonged headache with focal neurological signs when MRI evidence of dural thickening is detected, and another focus of tuberculosis was not found. Prompt suspicion with image-guided dural biopsy for histology would help to confirm the diagnosis.

Background. Rickettsial illnesses are a group of arthropod-borne remerging diseases. They are subdivided into three groups as typhus, spotted fever, and scrub typhus group. Complications such as reversible bilateral deafness due to spotted fever rickettsioses are infrequently reported in the literature. Case Presentation. We present a young pregnant female who developed bilateral sensorineural deafness on the fifth day of an acute febrile illness with a maculopapular rash. Rickettsia conorii IgG (>1/450) became highly positive, and she received oral azithromycin for ten days with complete resolution of fever and rash. The sensorineural deafness slowly improved over several months. Conclusion. Sensorineural deafness is a rare complication of spotted fever group rickettsioses. Since usage of doxycycline is controversial in pregnancy, azithromycin gave a favourable recovery of fever. Sensorineural deafness took several months to resolve after completion of antibiotics.

Background Prolonged pyrexia and weight loss are recognised paraneoplastic manifestations of renal cell carcinoma (RCC). Stauffer's syndrome is a rarely described paraneoplastic manifestation, which is described early in the course of RCC. We report a patient who presented with unresolving fever with multiple pulmonary opacities with biochemical evidence of hepatic choleastasis and was later diagnosed to have metastatic RCC with Stauffer's syndrome. Case Presentation We report a 54-year-old female who was investigated for a poorly resolving fever and recent weight loss for two months. During her course of illness, she developed bilateral multiple opacifications in the chest radiograph with negative pyogenic, mycobacterial microbiological studies. Despite intravenous antibiotics, her fever continued. She was found to have elevated alkaline phosphatase and gamma-glutamyl transferase and she underwent imaging with ultrasound scan of abdomen twice, which did not reveal demonstrable abnormalities. Later, contrast CT of abdomen and chest was performed and detected a renal cell carcinoma of the right upper pole of the kidney with multiple lung metastases, which was concluded as a metastatic RCC with paraneoplastic Stauffer's syndrome. Conclusion Prolonged pyrexia with loss of weight and Stauffer's syndrome could be features to suggest renal cell carcinoma in the absence of positive microbiological studies. Isoechoic RCC could be missed in routine ultrasonography. When a RCC is suspected in the setting of a pyrexia of unknown origin, ultrasound with doppler or a contrast CT should be requested to aid diagnosis.

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