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A 34 year-old man with AIDS
A 34 year-old man with AIDS (CD4 105, VL 200,000 last month) is transferred from an outside hospital
for further management of right-sided weakness for a week and an abnormal CT scan. He tested HIV+
five years ago after an episode of right mid-thoracic shingles. He has had no major opportunistic
infections and has been offered HAART on several occasions, but has been resistant to starting
treatment because some of his friends have had side effects. He takes no medications and denies illicit
drug use. Last week he developed a headache, fevers, followed by weakness of the right arm and leg,
and slurred speech. His PCP sent him to the ER where he was described as awake and aphasic, with a
right hemiparesis. Chem 7 was normal and CBC showed mild anemia and wbc 5.4 with a lymphocytosis.
The report of a head CT with and without contrast noted generalized cerebral atrophy with a 2cm ringenhancing lesion with surrounding edema and mass effect in the left basal ganglia, with several smaller(click here)
lesions in the right thalamus and at the gray-white junction in the frontal lobes bilaterally. The
transferring hospital is in a rural community without a neurologist or neurosurgeon and his PCP and the
ED physician agreed it was best that the patient be transferred to a facility with easier specialty access.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor his condition and its treatment? What is the prognosis?