Case+5+Discussion

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Per radiologist at MGH: “Small hyperdense right hemispheric lesion with a lot of surrounding edema out to the gray-white junction and causing mass effect on the right lateral ventricle. Hyperdensity is likely not blood, probably just a hypercellular focus-- this could represent abscess (tubercular or bacterial), Toxoplasmosis, or CNS lymphoma.”
 * CT read:**

So we discovered a brain mass that could look anything in this HIV pos patient, but are we getting closer to a diagnosis?
 * Discussion:**

With minimal access to CD4s, a steady picture of immunodeficiency can be difficult. However with a CD4 of 271 in the absence of any recent episodes of thrush, this should in principle exclude lymphoma and toxoplasmosis (barring some transient drop in CD4 in the last year). And looking at the chronic clinical picture of this multiple month headache and neck pain we have difficulty believing that this is a brain abscess, leaving us with one most likely diagnosis: tuberculoma.

Of course from a birds eye view of the clinical situation the diagnosis was staring at us the whole time: HIV pos patient with weight loss, night sweats, fevers for over 6 months with cryptococcal neg CSF, brain mass, with history of TB x 2! The decision was made to start patient on CNS tuberculosis treatment. To be thorough we started fansidar as well though the clinical suspicion of toxo was low (as before).

CNS tuberculosis can range from tuberculous meninitigits to tuberculoma, representing 1% of all TB cases worldwide. HIV pos individuals have a 20% higher prevalence of CNS tuberculosis suggesting the significance of immunodeficiency. As in most medical conditions, the earlier the diagnosis the more improved the prognosis.

Working in areas of heavy tuberculosis burden I am finding that many medical quandaries are often tuberculosis until otherwise proven, and therefore the trial of treatment in resource poor areas is often the greatest clinical utility. Initiating TB treatment consists of an ‘intensive’ phase of RHZE as well as injectable streptomycin. This is followed by RH for 7 months. In addition to this treatment regimen there is a role for glucocorticoids for the first 21 days followed by a taper. Decreased risk of death has been demonstrated.


 * Trial of treatment:** Over the next month the vomiting stopped, the neck pain and headaches resolved, and I began to meet our patient in the market buying food and snacks in between her streptomycin injections. It’s a truly remarkable story of recovery, the power of medicine, and hope in the midst of so much suffering. We providers cling to these cases here as death is an all too often occurrence in this hospital. She was discharged 2 months after initiating treatment ambulatory with a big smile.


 * Repeat CT demonstrated at discharge:**