Anti-NMDA receptor encephalitis and Facklamia languida septicaemia: initially unpronounceable but eventually treatable

Two interesting and contrasting case reports in this month’s issue illustrate how precise microbiological and serological diagnoses can transform treatment decisions, even if some of the clinical features remain unexplained [1,2]. In the first, the initial and final clinical diagnosis was sepsis. An unusual organism (Facklamia languida) is eventually grown from blood cultures, but its connection-apart from it being able to cause the physiological complications of sepsis-to the neurological features is not clear, despite the promising title [2]. During the course of the illness, the neurological catch-all term ‘stroke-like’ is used to denote a constellation of deficits even though advanced brain and vascular imaging suggests that it was not, radiologically, like a stroke. An unwitnessed seizure complicated by a Todd’s paresis is invoked as another possible explanation despite the (radiological) absence of an obvious (and irritative) cortical lesion. However, the authors clinch a peachy and precise bacteriological diagnosis, start the right treatment and suggest a decompensation of cerebral function as the most likely explanation. This is a handy concept, in the circumstances, and although difficult to verify or refute, experienced clinicians know that if an ageing brain is exposed to sepsis, hypoxia or any other systemic insult the resulting clinical problems can be asymmetrical (or focal), without an obvious imaging correlate. Whether readers think it sepsis-like or stroke-like the case serves as a very relevant cautionary tale for clinicians involved with thrombolysis: sepsis is one of many conditions that mimic acute stroke but which have more effective and less hazardous treatments, particularly if delivered with the same sense of door-to-needle urgency. If sepsis mimics stroke, the various stages of anti-N