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Recheck CD4 and HIV viral load serologies
0%
0/5
Lumbar puncture
MRI brain with contrast
CT head without contrast
40%
2/5
Neurological exam with fundoscopy
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The clinical presentation is concerning for meningoencephalitis in a patient with HIV/AIDS. The most appropriate next step in management is to perform a neurological exam with fundoscopy. Meningoencephalitis should be strongly suspected in HIV/AIDS patients with CD4 counts less than 100 cells/uL who present with fever, headache, or altered mental status. The differential diagnosis includes cryptococcus, tuberculosis, toxoplasmosis, CNS lymphoma, neurosyphilis, progressive multifocal leukoencephalopathy, and viruses such as cytomegalovirus, herpes simplex, and varicella zoster. These may be differentiated based on blood tests, cerebrospinal fluid (CSF) studies, and CT/MRI imaging. This patient is an HIV-positive man with AIDS based on his recent CD4 count less than 200 cells/uL. One may suspect that his immune deficiency has continued to worsen given that he has not been on antiretroviral medication and was lost to follow up, putting him at high risk for opportunistic infections. His presentation of altered mental status is concerning for CNS infection. The patient’s management should begin with a full neurological exam and fundoscopy to assess for focal neurological deficits or papilledema that would suggest elevated intracranial pressure (ICP) from an underlying mass. If exam is unrevealing, a STAT CT head is needed to further assess for intracranial masses and cerebral edema. Finally, if physical exam and CT are unremarkable, lumbar puncture may be performed to measure the intracranial pressure and obtain CSF studies. Incorrect Answers: Answer 1: CD4 and viral load serologies will be helpful to re-stage the patient’s HIV/AIDS and can be useful long-term for monitoring of anti-retroviral treatment. Answer 2: Lumbar puncture is essential for diagnosing meningoencephalitis, but clinicians must adequately rule out elevated ICP due to a cerebral mass by first performing a neurological exam. Answer 3: MRI with contrast can be helpful to further characterize findings on CT, such as abscesses due to bacterial versus fungal infection or ring-enhancing lesions due to CNS lymphoma versus toxoplasmosis. Answer 4: CT head without contrast would be performed after a neurological exam to help evaluate for masses and edema/mass effect. In advanced HIV infection, central nervous system infections and malignancy can cause variable symptoms and may indicate the location and severity of the underlying disease. Those with solitary lesions may have headache or focal deficits whereas those with multiple masses and associated elevated ICP may have visual disturbances, nausea, or altered level of consciousness (1).
3.8
(4)
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