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Case of the Month - January 2012

A 40-year old immigrant from Democratic Republic of Congo presented to a Cape Town hospital following a seizure. He had flown to South Africa 1 year previously from his home in Kibibi village, Bandudu, DRC and had been well until 4 months prior to admission. His friend had noted a slowing of his thought processes, and increased somnolence.

One week prior to admission, he developed fever and shivering. Examination reportedly revealed a thin man with slowed affect, a temperature of 38.4oC and firm posterior cervical lymphadenopathy. Chest x-ray showed bilateral hilar adenopathy, but no pulmonary infiltrate. 4th generation HIV ELISA – negative.

Lumbar puncture:

Lymphocytes 49, polymorphs 0, red cells 0
Protein 0.77, glucose 4.2 (blood glucose 6.1)
Cryptococcal latex antigen test – negative
Acid fast bacilli - negative.
FTA and VDRL – negative

He was started on empiric therapy for TB meningitis with Rifafour (rifampicin, isoniazid, pyrazinamide and ethambutol) plus prednisone.

One month later, he was transferred to a tertiary level hospital, having failed to respond to therapy. On presentation, he was somnolent, his speech was markedly slowed and he was disorientated in time, place and person. He had a Parkinsonian tremor of the upper limbs, but no other focal neurological deficit. Posterior cervical chain lymphadenopathy was present and there was no change in his chest x-ray appearance. Ultrasound scan of the abdomen revealed retroperitoneal adenopathy and a bulky spleen measuring 12.5cm

Repeat lumbar puncture showed 20 lymphocytes, 14 polymorphs, protein 0.57 and glucose of 2.7.

Question 1: What is the diagnosis and construct a differential diagnosis for this man’s presentation?

Continue to Answer 1