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Updated June 30, 2004

Case 3: A 36-Year-Old with Headache, Fever, and a Seizure

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

A 36-year-old HIV-infected man presented with a 2-3 week history of fever and headache and was brought in to the emergency room after having a grand mal seizure. His most recent CD4 count was 14 cells/mm3 and HIV RNA was greater than 500,000 copies/ml. He is known to be IgG seropositive for Toxoplasma. The patient had taken trimethoprim-sulfamethoxazole (Bactrim, Septra) and HAART about 1 year ago, but stopped after becoming tired of taking medications. He has a history of Kaposi’s sarcoma. In addition, the patient has a history of injection-drug use and now has moderate alcohol use. He is not taking any medications. Physical examination shows a confused patient with a temperature of 38.6°C, cutaneous Kaposi’s sarcoma lesions, and no focal abnormalities on a cursory neurologic examination. Contrast brain CT scan demonstrates focal mass lesions (Figure 1 and Figure 2).

Which of the following is TRUE regarding evaluation of this patient’s presentation?

A The presence of more than one mass lesion rules out central nervous system lymphoma.
B Approximately 10% of primary central nervous system lymphomas in patients with AIDS are associated with Epstein-Barr virus (EBV). Performing cerebrospinal fluid (CSF) PCR does not usually provide useful information.
C Based on the clinical presentation and the radiographic findings, the most likely diagnosis is primary central nervous system lymphoma. Radiation therapy should emergently be arranged.
D Based on the clinical and radiographic findings, the most likely diagnosis is Toxoplasma encephalitis. Empiric therapy with pyrimethamine (Daraprim) plus sulfadiazine plus leucovorin should be started.
  • The following link will open in a new window.
    Figure 1. Contrast Brain CT Scan (First View)

    The scan shows 2 ring-enhancing lesions in the right cerebral hemisphere, each measuring approximately 1.5 cm in size. There is moderate edema surrounding the lesions, but no midline shift or hydrocephalus. The lesion in the mid-frontal lobe is most evident on this cut of the CT scan; the lesion at the fronto-parietal junction is best seen in Figure 2.


    Figure 1
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    Figure 2. Contrast Brain CT Scan (Second View)

    The scan shows 2 ring-enhancing lesions in the right cerebral hemisphere, each measuring approximately 1.5 cm in size. There is moderate edema surrounding the lesions, but no midline shift or hydrocephalus. The lesion at the fronto-parietal junction is most evident on this cut of the CT scan; the lesion in the mid-frontal lobe is best seen in Figure 1.


    Figure 2