case

1. TikurAnbessaHospital AddisAbaba
Name:mohamodAli Age:30 Sex:M Occupation:private work : religion- muslim
Address:bole AA Date of Admission:22-9-2014 a weekago
Department:Internal Medicine Ward: B-8 BedNo:818/1 Marital Status:unmarried
Date of Clerking: yesterday Source of History:hisbrother handedness- righthanded
Previous Admission
None
cc- alteredmental statusof 3 days duration
Thisis a 30 year oldnewlydiagnosed RVIpatientof 1 week durationwith abaseline CD4count of
18/ml, andhas started antiviral medications 2days back.He was relativelyhealthyamonthagoat
whichtime presentedwithaprogressive change of mentation. Associatedwiththishe has a severe
headache thatinvolve bothsidesof the headanditwas notassociatedwithvomiting oranyneck
stiffnessorfever, thatusuallysubsidedwithmedications. He alsohadunquantifiedbutsignificant
weightlose forthe pastone month.A weekagothe patientssituationworsend andhe startedto
develop progressivechange inmentationthatfirststartwith confusion associatedwithleftsidebody
weakness.Forthiscomplaintthe patientwenttolocal healthcenterandhe wasreferredoBLH for
furtherinvestigations.Onhisarrival the patientsconditionworsenedandhe developed impaired
consciousness,fecal andurinaryincontinence,abnormal bodymovementof the arms, fever,excessive
nightsweat,nonbilous,nonbloodstingedprojectile vomitof injestedmatterwithfrequencyof 2x /day.
Otherwise the patenthasno historyof hypertension,DiabeticMellitusorcardiacillnesses,asthma.No
historyof headtrauma,earache or discharge.Nohistoryof forgetfulness, nervous breakdown,visual
disturbancesorinsomnia,seizureorepilepsy.Nodiarrhea,melenaorhematemesis.Nodysuria,red
discolorationof urine,lossof hearing,rashes,ulcersoverthe genital area. Noenlargedmassesoverthe
neck,axillaorgroin.Nohistory of chest pain,chroniccoughorcontact witha chronic cougher. Nohistoy
of alcohol use,cigarretsmoke,andanyotherdruguse.He has no exposure toindustrialsmoke or
wastes. There isno famiyhistoryof DM,HTN, epilepsyoranyothersimilarcondition.
came to blacklionhospital supportedbyhisbrother.
Past illness
No chickenpox,mumps,small pox oranyotherchildhooddiseases.
Nosurgery,trauma,psychiatryproblemsordrugallergy.
Head:SEE HPI.

2. Ears:SEE HPI.Notinnitus
Eyes:SEE HPI.No strain,lacrimation,oritching
Nose:No epistaxisordischarge.
Mouse and throat:Nodental pain,bleedingfromthe gums,sore throator tonsillectomy.
Glands:SEE HPI. Noheat or coldintolerance.
Respiratory System:SEEHPI.Noexpectoration,hemoptysis,shortnessof breath,wheezing orstridor.
Cardiovascular system:Nodyspnea,palpitation,orthopnea,paroxysmal nocturnal dyspneaorsyncope.
Gastrointestinal system:SEEHPI.No lossof appetite,dysphagia,abdominal pain,tarryorclaycolored
stool.
Genitourinarysystem:SEEHPI.No flankpain, urgency,hesitancy,dribblingorpyuria.
Integumentarysystem:SEE HPI.Moistskin,nochangesinhairdistributionorpigmentation.
Allergy:SEEHPI.Nodrugsensitivityorfoodallergy.
Locomotory system: Nobonydeformities,nojointpain.
Central nervous system:SEE HPI.
Personal history
The patientwasborn in -------------30yearsagoand he was raisedas hos local friends.He attendedhis
educationinhistown.He wentto saudiarabiaona youngage forjob opportunities.He came back ----
yearsago.
Familyhistory
PE
GA –the paientisnotfullyconscious andcooperative.He hasprominentzygomaticboneswithsunken
eyesanddry lipandmucosa. He appearsto be ina cardiopulmonarystress.He has a tube inhisnose
and he has a decorticate posturing.
Vital signs
BP:90/60mmHg, rightarm, supine position Pulse:90/min.,radial artery,regular,full volume
RR:16/min, deep,regularrhythm T0
:36.70
c, axillary,morning

3. HEENT H.E.E.N.T
Head: Normal size,shape andhairdistribution,Noscar.
Ears: Normal contourof pinna.Clearexternal earcanal.
Eyes: Normal eyebrows.Noper-orbital edema,ptosis,exophthalmosesorstrabismus. The conjunctivae
are pale.The scleraare noticteric. The pupilswhere normal sizeandroundshapedwithregular
boarder.
Nose:The nasal septumisnotdeviated.There isnopolyporunusual discharge
Mouse and throat:The lips shownofissure,ulcerationorherpesbutthey are dry. The gums are intact
and showno ulceration.There are nocariousteeth,extractions,denturesorfilling.The tongue is
whitish doesn’tshowanyatrophy. The buccal mucosa isslightlydry.
Lymphatic and glandular system
There are noenlargedlymphnodes overthe occipital,posteriorandpre auricular,anteriorand
posteriorcervical,sub-mandibular,sub-mental,supra-clavicular,axillary,inguinaland epithrochlear
areas.
The thyroid isnot enlarged.
Respiratory System
Inspection:There isno cyanosis orclubbingor the fingernails.Thepalmsare not pale.Breathing isdeep
and is of regular rate. The chestis symmetrical.There are nodeformities,surgical scars,visible
pulsationordilatedvessels.
Palpation:Thetracheais central.There is notendernessoverthe entire chest.The total circumferential
chestexpansionis3cm alongthe nipple lineondeepinspiration.Tactile fremitusisnormal over
the entire lungfield.Chestexpansionissymmetrical.
Percussion:Boththe rightandleftchestare resonant.Diaphragmaticexcursion is3cm.
Auscultation:The breathsounds are vesicularoverthe entire the lungfield.Nowheezing,crepitations,
stridoror pleural frictionrub.

4. Cardiovascular system
Arteries:BP and pulse (see undervital signs).There isnohardeningof the vesselwall.Pulse volumecan
be tabulatedasfollow:
Carotid Axillary Brachial Radial Femoral popliteal PT DP
Right +++ ++ ++ ++ +++ ++ ++ ++
Left +++ ++ ++ ++ +++ ++ ++ ++
No radio-femoral delaydetected.
No bruitoverthe carotidor femoral artery.
Veins:There are no distendedveinsoverthe neck,chestwall,orleg.
JVP observedatan inclinationof 450
is2 cm above the angle of Louis.
No Hepato-jugularreflex.
Precordium
Inspection:There isno precordial bulge.The precordiumisQuiet.The apical impulse isvisible atthe fifth
intercostal space alongthe midclavicularline.
Palpation:The pointof maximumimpulseis feltwhereit’sseen.The heartsoundsaren’tpalpable.There
isno parasternal or apical heave.There isnothrill.
Auscultation:Both heartsounds are normal overthe valvularareas.There are no addedheartsounds
(split,gallop,ejectionclick,openingsnap) ormurmurs.
Gastrointestinal System
Inspection:The abdomenis flat,symmetrical andmoveswithrespiration.The flanksarenotfull.There
are no surgical scars,massesordilatedveinsoverabdomen.The umbilicusisinverted.Herniasitesare
free. Novisible pulsationorperistalsis.Nocaputmedusae.

5. Auscultation:The bowel soundis normo-active.There isnobruitoverrenal artery, abdominal aortaor
liverareas.
Palpation:
 Superficial palpation: There was no muscle spasm, or superficially palpable mass. There was
alsono director reboundtenderness.
 Deeppalpation:The liverwasnotpalpablebelow the rightcostal margin. The spleen isalsonot
palpable.
Percussion:There is no shiftingdullness, fluidthrillorflankdullness.The total vertical spanof the liver
alongthe right mid-clavicularlineis 8 cm.
Genitourinary System
Kidneysare notpalpable.There isnohydro-cele,penile ulcerorurethral discharge. Bothtesticlesare
descendedandwithoutmass. There iscatheterinsertedtothe urethraandit has530 ml of urine
Integumentary System
The skinis warmwithno rash, scars or ulcers.There isnoabnormal hairdistribution.The nailsdon’t
showspooningorclubbing.
Locomotory System
There isno muscle tendernessorspasm.There isno bone deformityortenderness.There isnostiffness
of the joint.
Nervoussystem
GCS- E4V2M5= 11/15
Cranial nerve- the pupilswerereactiveforbothdirectandconcencually.The pupilswereequal and
normal I size withroundregularboarder.The others were’tabletobe examined
Motor
Bulk- comparable bilaterallybothon upperorlowerlimb
No inducedorspontaneousfasciculation
Tone –hypertonic(spastic) bilaterallyonbothUL OR LL.

6. Power–rightside preference
Reflex 3+bilaterally onthe knee
Babinski:Normal plantar reflex onthe right foot but equivocal on the leftside
Sensorycouldn’tbe assessed
Meningeal sign
There wasneck stiffness
 Kernig'sSign isnegative.
 Brudzinski'sSignisnegative.
Summary – thisisa 30 yearnewlydiagnosed RVIpatient.He presentedwith change of mentation of ----
-----durationand headache of one monthdurationand leftside bodyweeknessof aweekduration.
Fever,lossof consciousness,urinryandfecal incontinence,abnormal bodymovementof daysduration.
Objective
The patiethas GCS of 9/15. Withrightside preferenceandhypertonicandhyperreflexiclimbs.
Differential Diagnosis
 Cryptococal meningitis
 Asepticmeningitis
 Tuberculosmeningitis
 Neuro-syphilis
 Cerebral toxoplasmosis
 Brainstem lesions
 Epidural hematoma
 Epidural abscess
 Intracerebral haemorrhage
 Intracerebral tumours
 Intracerebral abscess
 Large hemispheric strokes
 Subarachnoid haemorrhage
 Subdural hematoma

7. 
Discussionof Differential Diagnosis
 Neuro-syphilis
Neurosyphilis isacomplicationof late syphilisandcanbe asymptomaticormay presentasacute
meningitis,withheadache,nausea,vomitingandneckstiffness, changesinmental status ,whichare in
accordance withthe findingsinthispatient.Butlackof cranial nerve involvement,neuroretinitis,
deafness,seizures,andlackof historyof penile ulceraren’tsupportiveof the diagnosis.
 Tuberculos Meningitis
It resultsfromthe hematogenousspreadof primaryorpostprimarypulmonaryTBor fromthe rupture
of a subependymal tubercle intothe subarachnoidspace.The diseaseoftenpresents withsevere
headache,lethargy,neckrigiditylow grade fever anorexia,irritability whichare consistentwiththe
findingsinthispatient whichareafrequentfindinginpeople sufferingfromtuberculosmeningitis,make
thisdiagnosislikely.butthe patienthasnohistoryof previousTBdisease,chroniccoughorcontact with
a chronic cougher
 Aseptic meningitis
It isan immune mediateddiseasewhichcanoccurat anytime inthe course of HIV infection,most
commonlyatthe time of acute HIV infection.Mostof the symptomslike headache,,nuchal rigidity are
presentinthispatient sothis is still asuitable diagnosis.
 Cryptococcal Meningitis
It iscausedby Cryptococcusneoformans,whichisayeastlike fungi.Itis the leadingcause of meningitis
inpatientswithAIDSandis particularlycommoninpatientswithAIDSinAfrica.Itusuallypresents with
lowgrade fever,nausea,vomiting,headache,neckstiffnessandphotophobia,whichare presentedin
thispatientandmake thisdiagnosisverylikely.
Cerebral toxoplasmosis

8. The most commonsigns and symptoms are headache (38%-93%), focal neurological
deficit (22%-80%), fever (35%-88%), mental confusion (15%-52%), seizures (19%-
58%), psychomotor or behavioral changes (37%-42%), cranial nerve palsy (12%-
28%), ataxia (2%-30%), and visual abnormalities (8%-19%
Diagnostic Workup
 Complete BloodCountwithdifferential –toassessif there isinflammatorystate.
 ESR – to assessif there isinflammatorystate
 Lumbar Puncture withCSFanalysis - toassessthe WBC withdifferential,protein,glucose and
LDH inorderto identifywhichtype of meningitisitis.Indianink –foridentificationof
cryptococcal meningitis.Darkfieldmicroscopy –neurosyphilis.
 Brain Imagingsuchas CT and MRI – to evaluate if there are complicationssuchas
hydrocephalus,briskmeningealenhancementand/orintracranial tuberculoma.
 Venereal DiseasesResearchLaboratory(VDRL) testand Fluorescenttreponemal antibody-
absorbed(FTA-ABS) Test- Serological Testsforsyphilis