Case+5+-+Continued

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Clinically with the given history of an HIV + patient with weight loss, fevers, night sweats, headache, neck pain in context of exam findings with neck stiffness clearly meningitis is a likely diagnosis (bacterial, viral, tuberculous, cryptococcal, syphilitic, lymphomatous) vs intracranial pathology. The LP only seemed to further confuse the diagnosis however:

//**Bacterial**//: The chronic time course does not fit classic bacterial origin, and neither does the LP with WBC of 8 counted on the field.

//**Cryptococcal:**// The symptoms and time course fit well with this etiology given chronicity and general worsening, however with 2 negative CSF cryptococcal Ag (sensitivity 93-100%) 2 months apart, the likelihood is very low.

//**Tuberculous:**// The clinical course highly suggests with weight loss, fevers, night sweats with progressive chronicity, all in context of an HIV pos individual with history of TB twice! CSF typically with WBC 100-1000 with lymphocytic predominance, as well as classic elevated protein. Unfortunately with lack of reagants, our low WBC count does not seem to agree. Also no AFB seen on smear – of note only 20-50% sensitivity for finding AFB in CSF.

//**Aseptic / Viral:**// clinical history does not seem to fit with time course. However slightly elevated WBC in LP would seem to agree.

//**Lymphomatous:**// RARE diagnosis with primary CNS lymphoma, with CSF demonstrating nonspecific leukocytosis and high protein, with diagnosis made on CSF cytology.

As no culture methods are available at the district level (urine, blood, CSF, body fluid), the clinical history, exam, and clinical labs are paramount in deciding a clinical course.

Suffice to say we were having a hard time believing the reported CSF cell count in the face of such concerning clinical course, and another LP sample allowed even a 3rd cryptococcal antigen.

Repeat LP result 1 week following initial: Cloudy CSF RBCs: none WBCs: 3000 cells à 80% polys, 8% lymphs, 12% monos No protein or glucose reagents available VDRL: negative AFB: negative Gram stain: negative Cryptococcal Ag: negative

Alright, so now we have 2 taps a week apart ENTIRELY different from each other. To trust the first or second?? Do we obtain a third and let majority rule? Of course the clinical case seems to agree with the second LP result but is that bias injected into the case?

While all this academizing was occurring, meanwhile the patient continued to deteriorate clinically. Specifically the patients headache continued worsen, she lost the ability to walk, and patient was noticed to suffer a seizure, with following decreased mental status that was not clearing as a typical post-ictal course would. Deteriorating condition…

Around the same time we were investigating partnering with hospital with CT Scanner in regional capital for discount CT scans for district level patient. Given confusing LP results, worsening condition with headache in HIV positive patient, decision made to obtain CT scan.





//How do you describe the above CT images?// //How does this further refine your diagnosis/differential?//