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Double vision for a week and increasing confusion
A 51 year-old homeless man is sent to the ED by his PCP for three weeks of headache, double vision for
a week, and increasing confusion for five days. His friends brought him to his PCP and said that before
the headaches started, the patient had lost weight and had night sweats. They indicate that he drinks
heavily on weekends, but doesnʼt get the shakes or use IV drugs. The PCPʼs referring note describes a
long history of depression with psychotic features and poor medication adherence and a negative HIV
test two years previously. On examination, he is a disheveled, thin man appearing older than his stated
age, with a temperature of 37.5. His neck is markedly stiff. He is distractible, mumbles short sentences
that variably relate to questions he is asked, and has decreased abduction of both eyes. He is unable to
cooperate with funduscopic examination and is diffusely hyperreflexic with extensor plantar responses
bilaterally.
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?
Case 26
A 51 year-old homeless man is sent to the ED by his PCP for three weeks of headache, double vision for
a week, and increasing confusion for five days. His friends brought him to his PCP and said that before
the headaches started, the patient had lost weight and had night sweats. They indicate that he drinks
heavily on weekends, but doesnʼt get the shakes or use IV drugs. The PCPʼs referring note describes a
long history of depression with psychotic features and poor medication adherence and a negative HIV
test two years previously. On examination, he is a disheveled, thin man appearing older than his stated
age, with a temperature of 37.5. His neck is markedly stiff. He is distractible, mumbles short sentences
that variably relate to questions he is asked, and has decreased abduction of both eyes. He is unable to
cooperate with funduscopic examination and is diffusely hyperreflexic with extensor plantar responses
bilaterally.
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?