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An interesting case of hemiparesis
  1. S Arora,
  2. A Arora,
  3. R P S Makkar,
  4. A Monga
  1. Department of Medicine, Sitaram Bhartia Institute of Science and Research, New Delhi, India
  1. Correspondence to:
 Dr Ravinder P S Makkar, Department of Medicine, Sitaram Bhartia Institute of Science and Research, B-16, Mehrauli Institutional Area, New Delhi, India; 
 makkar_r{at}yahoo.com

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Answers on p 359.

A 40 year old man was brought to the hospital with a history of pain and progressive diminution of vision in his left eye for one month, weakness of left half of body for 15 days, and altered sensorium for five days. There was no history of fever, cough, headache, vomiting, seizures, or trauma to the head. The relatives denied any history of sexual contact outside marriage, intravenous drug abuse, or recent travel by the patient. There was no significant illness in the past, including tuberculosis. On examination, the patient was conscious but drowsy and disoriented. His pulse rate was 90 beats/min, blood pressure was 130/80 mm Hg, and respiratory rate was 20 breaths/min. General physical examination and systemic examination of chest, cardiovascular system, and abdomen was normal. Neurological examination revealed left sided hemiparesis and left upper motor neurone facial palsy. There were no meningeal signs and fundus examination showed pallor of the left optic disc suggestive of optic atrophy.

Initial laboratory investigations revealed a haemoglobin concentration of 99 g/l, total leucocyte count of 5.6 × 109/l, with a normal differential count. Other routine investigations including blood glucose, liver and kidney functions, urine examination, chest radiography, and electrocardiography were normal. Cerebrospinal fluid examination revealed 5 lymphocytes/high power field with normal proteins and glucose levels. No acid fast bacilli, fungus, or malignant cells were seen and polymerase chain reaction test for Mycobacterium tuberculosis was negative. Computed tomography and magnetic resonance imaging (MRI) of the head are as seen in figs 1 and 2 respectively. Enzyme linked immunosorbent assay (ELISA) for HIV was reactive and western blot was confirmatory for HIV-1. CD4+ count was 30/μl. Serological tests for syphilis were non-reactive. Stereotactic brain biopsy was suggested but was refused by the patient’s family. Highly active antiretroviral therapy (HAART) was started but the patient continued to deteriorate and died on the fifth day of admission.

Figure 1

Contrast enhanced computed tomogram of head.

Figure 2

MRI of head: (A) T1 weighted sagittal image and (B) T2 weighted coronal image.

QUESTIONS

  1. What is the differential diagnosis in this patient?

  2. What are the computed tomography and MRI findings?

  3. How is the diagnosis confirmed?

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