Quick Thinking #1

March 30, 2007

ThinkWelcome to Quick Thinking a new feature of Clinical Correlations. A case will be presented piece by piece to a faculty expert who will comment on their approach to the case as it unfolds. Differential diagnoses and diagnostic workups will form the basis of these posts of difficult clinical cases. So for the next 4 Fridays we present our first case to our discussant Mitchell Charap:

The Case Presented by Elizabeth Ross, PGY-3: The patient is a 35 year old African American male prisoner with no significant past medical history. He was in his usual state of health until 3-4 months prior to admission when he experienced a gradual onset of intermittent headaches, weight loss, intermittent dizziness and blurred vision of his right eye. He also reports that over the last month he has had subjective fevers and nausea with vomiting. His weight loss has been unintentional and he has lost 70 pounds in the last 3 months. He describes his headaches as global and they were not worse at any particular time of day, nor was he able to identify any provocative or palliative circumstances.

The patient denied recent travel and was unemployed. He had been an inmate at Riker’s Island prison ward for approximately 4 weeks. His symptoms preceded his stay at Riker’s.

Commentary: Mitchell Charap, MD Abraham Sunshine Associate Professor of Medicine
In our prison population the constellation of fever and weight loss over months suggest HIV infection and/or Tuberculosis. The headache, if the patient is HIV positive, suggests. infectious disorders such as central nervous sytem toxoplasmosis or cryptococcal meningitis come to mind. Clearly CNS lymphoma is also a possibility.

The nausea/vomiting suggest increased intracranial pressure, and the dizziness and blurred vision (right eye) suggest focality. Clearly the patient needs imaging studies and then a lumbar puncture. In the physical exam I would be interested to see if the patient appeared chronically ill. I would imagine that he was febrile. The neurologic exam will help corroborate the suspicion that there is a focal deficit. I would also have neurology and ophthalmology see the patient. The former to help pinpoint the problem and the latter to ensure that visual fields and extraocular muscles were intact.

To be continued…

One Response to Quick Thinking #1

  1. Ann Danoff on April 6, 2007 at 3:00 pm

    I am in full agreement with Dr. Charap with respect to concern of HIV status, TB, and/or other opportunistic infections and/or CNS lymphoma. Given constellation of presenting findings (headache, visual disturbances, unintentional weight loss, nausea/vomiting, fever) would also consider sellar or parasellar lesion and possibility of central adrenal insufficiency. In addition to f/u suggested by Dr. Charap, can we also obtain 3 morning cortisol’s (7, 7:15, and 7:30 AM) to assess integrity of the hypothalamic-pituitary-adrenal axis? Dr. Charap’s concern and mine are, of course, not mutually exclusive. HIV+ patients have been reported with OI’s and CNS lymphoma resulting in panhypopituitarism.

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