A Sexually Active 23-Year-Old With Seizures and Tongue Pain

Manuel Salinas, MD

Disclosures

October 05, 2021

Physical Examination and Workup

Upon physical examination, during the development of his altered mental status, the patient's temperature is 97.7°F (36.5°C), his pulse is regular at a rate of 100 beats/min, his blood pressure is 100/50 mm Hg, and his respiratory rate is 16 breaths/min. A normal S1 and S2 are auscultated, with no murmurs or rubs. His lungs are clear in all fields. Palpation of the abdomen reveals no tenderness, masses, or enlargement of the liver or spleen. His mucous membranes are pale and the tongue has diffuse, creamy white exudates, which, when scraped, leave a bleeding, ulcerative surface. The neurologic examination reveals stupor, a dense left-sided hemiparesis, seventh cranial nerve palsy, and an extensor plantar response on the left. No pupillary abnormalities are noted.

Laboratory testing is performed and includes a complete blood count (CBC) that reveals anemia with a hemoglobin concentration of 9.4 g/dL (94 g/L) and a hematocrit of 29% (0.29). His white blood cell (WBC) count is within the reference range, except for 63% (0.63) lymphocytes. The erythrocyte (globular) sedimentation rate is elevated at 62 mm/hr. Complete metabolic panel findings, including electrolytes and liver enzymes, are normal. Cerebrospinal fluid is not initially obtained because of a concern for increased intracranial pressure.

A CT scan of the brain is performed (Figures 1-4).

Figure 1.

Figure 2.

Figure 3.

Figure 4.

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