C linical C ase of the M onth
Altered Mental Status and Headache in a Young Man
Faisal Musa, MD; Jorge A. Martinez, MD, JD; Catherine Hebert, MD; Matthew Safley, DO; David Smith, MD; Fred Lopez, MD
INTRODUCTION Central nervous system (CNS) toxoplasmosis can be a life-threatening disease in patients with human immu- nodeficiency virus (HIV) infection. 1 We describe a case of a young adult man with acquired immune deficiency syn- drome (AIDS) who presented with altered mental status and headache secondary to toxoplasmosis. CASE PRESENTATION A 31-year-old man with advanced human immunode- ficiency virus (HIV) infection presented to the emergency department with a chief complaint of worsening confusion for several weeks. He had been having headaches intermit- tently for about a year, which had progressively worsened over the last month. He denied cough, fever, chills, weak- ness, weight loss, tremors, or visual disturbances. He had a history of smoking tobacco and marijuana. He lived alone.
He had not seen a provider for more than a year and had not taken antiretroviral therapy during this time. His CD4 cell count 18 months earlier was 299 cells/mm 3 (Normal Reference Range is 228-2,290), andCD4%was 18.1%(Normal Reference Range is 37%-63%). Upon admission to the emergency department, his tem- perature was 97.3˚F, heart rate 64 beats/minute, blood pres - sure 120/83mmHg, respiratory rate 16/minute, and oxygen saturation of 100% on room air. He weighed 52 kilograms. His height was 167 centimeters. His body mass index was 18.6. On physical examination, he was alert and oriented to place and person andwas dysarthric. The rest of his physical examination revealed no reported abnormalities. His laboratory workup revealed a normal complete blood count and comprehensive metabolic panel. His CD4 cell count was 30 cells/mm, 3 and CD4% was 5%. His urine toxicology test was positive for marijuana and cocaine. ACT scan of the brain showed large left frontal and left temporal lesions with edema and a 3.8 cmheterogeneously enhancing
Figure 1: An axial T1- weighted post-contrast image with fat saturation demonstrates an irregularly enhancing left frontal lobe mass (arrow).
Figure 2: T2 FLAIR imaging at a slightly higher level reveals smaller lesions in the right hemisphere (arrowheads).
J La State Med Soc VOL 166 January/February 2014 41
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