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A 33 year old Indian man, a truck driver in Mumbai, who was seropositive for human HIV and not on antiretroviral therapy, presented with a one month history of intermittent fever with sweating, gradually progressive headache, vomiting, and watery diarrhoea. He had lost 9 kg of weight in the past one month. He had smoked cigarettes for 15 years and had multiple unprotected sexual exposure in the past. He denied having had any significant illness.
On physical examination, he was emaciated, febrile, and behaving abnormally. He was irritable and restless. He was unkempt and appeared withdrawn socially with a general loss of interest. Sometimes he would answer relevantly and at other times he would become silent with a vacant stare as if unaware of his surroundings. Waxing and waning of alertness and attention deficits progressed to deeper levels of drowsiness during the hospital stay. He was anaemic with mobile, non-tender enlarged lymph nodes (3–5 cm) in the cervical, axillary, and inguinal areas. There was oropharyngeal candidiasis. His liver was enlarged 3 cm below the right costal margin; his spleen was just palpable. There were no signs of meningial irritation and no focal neurological deficits.
His haemoglobin concentration was 80 g/l, leucocyte count 2.3 × 109/l with 28% lymphocytes, CD4 count absent, and erythrocyte sedimentation rate 8 mm in the first hour. Serum glucose, renal function, electrolytes, calcium, and phosphate were within normal limits. Liver function was abnormal with a threefold rise of alanine aminotransferase (130 U/l) and aspartate aminotransferase (146 U/l). Alkaline phosphatase was two times the normal level. Serum albumin was 28 g/l. Induced sputum was negative for acid fast bacilli andPneumocystis carinii, and for bacterial and fungal growth. Stool was positive for cryptosporidial oocysts. Hepatitis B surface antigen, the Venereal Disease Research Laboratory test,Treponema pallidum haemagglutination, and purified protein derivative test were negative. Electrocardiography, chest radiography, and computed tomography of the brain were normal. Abdominal sonography revealed mild hepatosplenomegaly without focal lesions. Cerebrospinal fluid (CSF) was under normal pressure without pleocytosis and glucose and protein concentrations in the CSF were normal. Fine needle aspiration cytology (FNAC) of the cervical lymph node showed abnormal findings. Microscopic pictures of stained CSF and FNAC samples are shown in fig1.
- What are the diagnoses?
- What is unusual and atypical in the case illustrated?