After Unprotected Sex, 50-Year-Old Has Rash, Severe Weakness

Amber M. Bokhari, MD

Disclosures

August 22, 2022

Physical Examination and Workup

Upon examination, the patient is febrile, with a temperature of 101.6 °F (38.7 °C). He has a blood pressure of 120/80 mm Hg, a heart rate of 100 beats/min, a respiration rate of 23 breaths/min, and an oxygen saturation of 85%.

He is cachectic and has a rash on his body that consists of widespread small papules, some of which are umbilicated. Lesions are noted on the face, abdomen, thighs, arms, and back. Some of the papules coalesce to form plaques. He also has oral thrush, with a white-coated tongue that bleeds on scraping. The head and neck examination reveals some nuchal rigidity and cervical lymphadenopathy. Bilateral crackles and coarse rhonchi are noted on lung auscultation. The remainder of the physical examination results are unremarkable.

A complete blood cell (CBC) count reveals a white blood cell (WBC) count of 11,000 cells/µL (reference range, 4000-11,000 cells/µL), with predominantly elevated lymphocytes. The urinalysis results are normal. The results of a comprehensive metabolic panel are within normal limits.

A rapid plasma reagin test and hepatitis B and C tests are negative. An HIV antigen/antibody test is positive for HIV-1, and the results of a polymerase chain reaction (PCR) test are pending. The results of urine Neisseria gonorrhoeae/Chlamydia trachomatis nucleic acid amplification tests and a cytomegalovirus quantitative PCR test are negative. A 1,3-beta-D-glucan test is positive, at 450 pg/mL. The results of urine and serum cryptococcal antigen tests, a urine Histoplasma test, an Aspergillus galactomannan test, a Quantiferon-TB Gold test, a Mycobacterium tuberculosis (MTB) probe, and Toxoplasma serology and PCR tests are pending. Blood, sputum, stool, and urine cultures have been ordered and are in progress.

A lumbar puncture (LP) is performed, with an opening pressure of 200-cm H2O. Cerebrospinal fluid (CSF) cytology shows a glucose level of 70 mg/dL (reference range, 50-80 mg/dL), a protein level of 30 mg/dL (reference range, 20-40 mg/dL), and a lymphocyte count of 200 cells/µL (reference range, < 5 cells/µL). The results of CSF cultures, Venereal Disease Research Laboratory (VDRL) test, and cryptococcal antigen test are pending. A biopsy sample of a skin lesion is obtained. Bronchoscopy is performed, and bronchoalveolar lavage (BAL) fluid is sent for an MTB probe; Pneumocystis jirovecii (Pneumocystis carinii) pneumonia (PCP), fungal, acid-fast bacilli (AFB), and other bacterial staining and cultures; and silver staining. The PCP test is negative, and the other stains and cultures are in progress. Silver staining is negative. The serum cryptococcal antigen test is negative. Empiric treatment of toxoplasmosis is started with pyrimethamine and sulfadiazine.

A chest radiograph shows lymphadenopathy, bilateral interstitial infiltrates, multiple pulmonary nodules, and small pleural effusions. An MRI of the brain with contrast reveals lesions in the left frontal lobe. Figure 1 demonstrates lesions similar to those in this case.

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