Case 1: A 39-Year-Old with Headache, Fever, and Confusion

Question | Discussion | References | CME Credit

Authors: David H. Spach, MD
Joel E. Gallant, MD, MPH

Case last updated: June 30, 2004

A 39-year-old woman with advanced HIV disease is evaluated in the clinic for confusion and headache. The patient was diagnosed with HIV 3 weeks prior and has a CD4 count of 23 cells/mm3 and HIV RNA of 211,000 copies/ml. Two weeks prior she was started on trimethoprim-sulfamethoxazole (Septra, Bactrim) and azithromycin (Zithromax), with plans to start antiretroviral therapy in the next several weeks. She has a 6-7 day history of headache, fever, and slight confusion. Her physical examination is normal except for a temperature of 38.4°C and a decreased performance on her mini-mental status examination. The patient undergoes a double-dose contrast brain CT scan that shows mild atrophy, but no mass lesions. A lumbar puncture is subsequently performed, and analysis of the cerebrospinal fluid shows 7 leukocytes/mm3, a glucose of 41 mg/dl, and a negative Gram’s stain. The cerebrospinal opening pressure was measured as 310 mm H2O. Previous labs have shown the patient is Toxoplasma seropositive.

Which of the following is TRUE regarding this patient?

	The diagnosis of Toxoplasma encephalitis is the most likely diagnosis even though the contrast brain CT is normal; approximately 40% of AIDS patients with Toxoplasma encephalitis will have a normal contrast brain CT.
	The patient's clinical history is compatible with cryptococcal meningitis. The diagnosis of cryptococcal meningitis should not be ruled out with only 7 leukocytes/mm3 found in the cerebrospinal fluid.
	The clinical history is most compatible with progressive multifocal leukoencephalopathy (PML). A cerebrospinal fluid test positive for Epstein-Barr virus (EBV) would be diagnostic of PML.
	If the patient has cryptococcal meningitis, management of the increased cerebrospinal fluid should be performed by giving mannitol and acetazolamide.