A 23-Year-Old Man With Neurologic Deterioration

Manuel Salinas, MD

Disclosures

July 13, 2016

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 23-year-old man in Cuba is brought to the hospital by his family with complaints of malaise, fatigue, a 22-lb (10-kg) weight loss, and a 10-month history of diminished appetite. He also complains of painful tongue erosions which are covered with a white, creamy exudate. Three days after admission to the hospital, the patient's mental status progressively declines, evolving from drowsiness to confusion. He is eventually found by the nursing staff to be stuporous. Soon afterwards, the patient experiences generalized tonic-clonic seizures and sudden dense left hemiparesis.

At the time that the patient develops altered mental status, his family states that he has also been having increasingly severe headaches without neck stiffness or fevers. The patient has not had any known trauma. He does not have any known risk factors for tuberculosis nor has he had any ill contacts. He has no previously diagnosed medical conditions and has not been taking any medications. No significant family history is reported. His social history is remarkable only for sexual relationships with men.

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