Twenty-five year-old
homosexual man cohabitates with his partner who is HIV positive. He has
yearly serological tests and he eventually becomes HIV positive. He begins
on HAART regimen and one year later has just detectable viral load and normal
CD-4 lymphocyte count. Despite feeling systemically well and functioning
as a university chemistry professor, he reports "memory problems" with difficulty
thinking and concentrating. Also, he reports insomnia, morning fatigue,
and poor appetite (but no weight loss is documented). His MMSE is 29 of
30. Neurological exam shows normal gait, strength, coordination, sensation,
and cranial nerves with 2 exceptions.
- several beats of unsustained
clonus at both ankles
- fundi show no spontaneous
venous pulsations.
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- What are your thoughts
as to the explanation of the clinical features of this case?
- What tests are warranted?
- Assume CT is normal and
CSF shows these results, what is the most likely diagnosis?
CSF Findings:
| Opening
pressure |
-
120 cm H20 |
| Cells |
- 28 all lymphocytes |
| Sugar |
- 63 mgm % |
| Protein |
- 58 mgm %
|
| Gram
stain |
= negative
|
| AFB Stain |
= negative |
| India Ink |
= negative |
| Syphilis serology |
= negative |
| Cytology |
= negative |
| All cultures |
= negative |
| |
|
| Gamma globulin |
= 8% |
- The professor stops all
medications, as he is certain he is dying. Six months later, he has
high viral load and CD-4 lymphocyte count of 6. One day he is found
in his office having generalized major seizure. Ambulance brings him
to the ED. CT is performed. What is the differential diagnosis?
- Read reference SMJ, March
2000 or neurological complications of HIV infection.
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