Case 6: A 44 year old male with HIV presents with a headache
Written by Mohammed H Mohammed, MD. Chief Resident, Department of Medicine, Wayne State University, Detroit, MI, USA Reviewed by Zahir Osman Eltahir Babiker, MRCP, MSc, DLSHTM, DTM&H. Specialist Registrar in Infectious Diseases & Virology, Manchester, UKHistory:
A 44 year old male with advanced HIV/AIDS (CD4 count of 4 cells/micro liter 2 months prior to admission) not on HAART (Highly Active Antiretroviral therapy) presented to the Emergency Department complaining of a headache for the last 14 days. He also complained of intolerance to light and neck stiffness. He vomited 3 times over the last 3 days. He denied any fever or night sweats. No hematemesis.
Past Medical History: HIV diagnosed 8 years prior to admission.
Social History: Smokes one pack per day for the last 30 years. No history of intravenous drug abuse. He had acquired HIV through female sexual contact.
Family History: Father had MI at the age of 62.
Drug History: None
Review of Systems: Photophobia, phonophobia, Poor appetite with 10 pounds (4.5 kilograms) weight loss in the last 3 months. Cough productive of yellowish sputum for the last 2 weeks.
Physical Examination:
Pulse Rate: 77/min, Temperature: 35 degrees celsius. Respiratory Rate: 20 breaths/min.
Blood Pressure: 112/83. Oxygen Saturation: 100% on Room Air
GENERAL: The patient appeared very cachectic with significant temporal wasting. He appeared in moderate distress especially with the lights on.
HEENT (Head, Eyes, Ear, Nose, throat examination): Pupils equal, round, reactive to light. Extraocular movements intact. Mild conjunctival pallor. No papilledema on funduscopic examination. Poor dentition. Moist mucous membrane. No oral ulcers. Non-scrapable white plaques were present on the left lateral tongue border.
NECK: His neck was stiff.
LUNGS: Symmetric chest expansion, clear to auscultation bilaterally. No crackles or wheezes heard. No dullness to percussion. No egophony appreciated.
Cardiovascular: S1, S2 present. Regular rate and rhythm. No murmurs, rub, or gallop. JVP was not elevated. No carotid bruit. Peripheral pulses palpable.
ABDOMEN: Soft, neither tender nor distended. No guarding. Bowel sounds heard in all quadrants. No organomegaly appreciated.
NEUROLOGICAL EXAMINATION: Confused and lethargic. Cranial nerves II through XII grossly intact. Strength 5/5 in all limbs. Kernig’s sign was positive but Brudzinski’s negative.
BACK/EXTREMITIES: No spinal tenderness. No CVA (costovertebral angle) tenderness. No skin lesions seen. No pedal edema. Dorsalis pedis and posterior tibial arteries scored 2+ bilaterally.
GENITALIA/RECTAL: Normal male genitalia. No lesions noted.