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Case of the Month - August 2018

A rare case of Salmonella Enteritidis meningitis in an HIV-infected patient


Dr Roxanne Rule, Dr Mohamed Said; Department of Medical Microbiology, University of Pretoria; Tshwane Academic Division, National Health Laboratory Services (NHLS)

Background

A 34-year-old man presented to the emergency department at a tertiary hospital in Pretoria on 6 June 2018 with a one-month history of headache and constitutional symptoms (non-productive cough, fever, loss of weight, and generalised body pain). A relative accompanying the patient reported that his symptoms had worsened over the preceding week, notably the fever and headache. In addition to the headache, the patient developed neck pain and then became confused. He had no history of vomiting, convulsions or skin rash. His relative was unable to comment on whether he had had a recent diarrhoeal illness.
There was no travel history of note. The patient was unemployed, and no household contacts had been ill.

Past medical history revealed that the patient was diagnosed with HIV about two years before admission. His CD4 count on admission was 2 cells/μl. The most recent HIV viral load available was 49 925 copies/ml in December 2017. His relative reported that the patient was taking fixed dose combination antiretroviral therapy (tenofovir, emtricitibine and efavirenz) but added that the patient was poorly adherent and had recently stopped treatment. There was no history of prior opportunistic infections.

Upon further enquiry as to social habits, the patient was reported to be an intravenous and inhalational drug user, and frequently used nyaope (a street drug cocktail containing antiretroviral drugs, heroin, marijuana and other substances). There was no history of alcohol use.

On arrival to hospital, he appeared acute on chronically ill but was haemodynamically stable with a blood pressure of 102/60, heart rate of 65 beats/min, oxygen saturation of 97% on room air, respiratory rate of 19 breaths/min and temperature of 36°C. His serum glucose level was 6.6 mmol/l.

Severe oral candidiasis was noted on general examination. On neurological examination, he was noted to be confused with a Glasgow coma scale (GCS) score of 12/15 and meningism, but no focal neurological deficits. The rest of the physical examination was unremarkable.

A chest X-ray showed no abnormalities.

Question 1: What differential diagnosis should be considered in this patient?


Continue to Answer 1