Weekly Case Study - Case 10

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.
  1. several beats of unsustained clonus at both ankles

  2. fundi show no spontaneous venous pulsations.

Images

  1. What are your thoughts as to the explanation of the clinical features of this case?

  2. What tests are warranted?

  3. 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%


  4. 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?
  5. Read reference SMJ, March 2000 or neurological complications of HIV infection.

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Films C-10 (2) - Revised 6/21/05