A 53-year-old woman presented with acute onset of bifrontal headache with fever and vomiting, and a 6-week history of unilateral, left-sided, clear, salty rhinorrhoea. She worked as a veterinary pathologist. On examination, her neck movements were painful, but there were no localising neurological signs. She was obese with a body mass index of 36.5 kg/m2(height 162 cm, weight 96 kg). Cerebrospinal fluid (CSF) examination identified a pleocytosis with a white cell count of 2910/µL (≤5), 91% polymorphs and 9% lymphocytes. The level of CSF glucose was low at 3.9 mmol/L, with a CSF/serum ratio of 0.66. CSF protein was markedly raised at 3.38 g/L (0.15–0.45). We made a presumptive diagnosis of bacterial meningitis and started antimicrobial cover as per local guidelines. This did not include corticosteroids or anti-tuberculous therapy. Given her occupation, and recent travel to Yosemite National Park, California, we excluded an extensive list of pathogens. CSF PCR was negative for Neisseria meningitidis, Streptococcus pneumoniae, Escherichia coli , Streptococcus agalactiae , Haemophilus influenzae , Listeria monocytogenes , cytomegalovirus, enterovirus, herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2), human herpesvirus 6, varicella zoster virus, …

中文翻译：

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非创伤性脑脊液鼻漏

一名 53 岁女性因急性发作的双额头痛伴发热和呕吐就诊，有 6 周单侧、左侧、清澈、咸味鼻涕。她曾担任兽医病理学家。检查时，她的颈部活动疼痛，但没有局部神经系统体征。她肥胖，体重指数为 36.5 kg/m2（身高 162 cm，体重 96 kg）。脑脊液 (CSF) 检查发现白细胞计数为 2910/μL (≤5)，多形性细胞数为 91%，淋巴细胞为 9%。CSF 葡萄糖水平低至 3.9 mmol/L，CSF/血清比率为 0.66。CSF 蛋白显着升高，为 3.38 g/L (0.15–0.45)。我们对细菌性脑膜炎进行了推定诊断，并根据当地指南开始了抗菌药物覆盖。这不包括皮质类固醇或抗结核治疗。鉴于她的职业以及最近前往加利福尼亚州优胜美地国家公园的旅行，我们排除了大量病原体。脑膜炎奈瑟菌、肺炎链球菌、大肠杆菌、无乳链球菌、流感嗜血杆菌、单核细胞增生李斯特菌、巨细胞病毒、肠道病毒、单纯疱疹病毒 1 型 (HSV-1) 和 2 型 (HSV-2)、人类疱疹病毒 6 的脑脊液 PCR 呈阴性水痘带状疱疹病毒……