30-Year-Old Male With Right-Sided Weakness

Robert M. Centor, MD; Umair A. Gauhar, MD

Disclosures

April 05, 2006

This series of cases offers an opportunity for you to work through the diagnostic process, determining what tests to order and which questions to ask. A discussion link is provided below to facilitate that process.

Case Presentation

This is a real patient case, and I present the protocol here exactly as I received it. You should be able to develop a differential diagnosis and possibly guess the correct answer.

History and Physical Information: A 30-year-old black male presented to the emergency department with right-sided weakness. The patient reported the acute onset of weakness at 8:00 AM while at work. The weakness involved the right arm and right leg; he was still able to walk but required assistance. Shortly before the onset of weakness, he noted diplopia when looking to the right. The weakness was associated with dizziness, nausea, and 4 episodes of emesis, but no vertigo. The patient initially went to his hotel room to rest, but decided to seek care 2 hours later as the symptoms did not improve.

The patient was in his usual state of health prior to the onset of the symptoms. He denied sensory and visual changes. There was no history of chest pain, palpitations, dyspnea, headache, or neck stiffness.

Review of Systems: 8-pound weight loss over the last 2 months; normal appetite; no diarrhea.

Prior Medical History:

HIV: diagnosed 3 months prior to this presentation, with CD4+ cell count of 550; no history of an AIDS-defining illness

Zoster: right maxillary nerve, 3 months prior; treated with IV acyclovir

Positive purified protein derivative (PPD) skin test 8 years ago; chest radiograph negative; not treated

Allergies: No known drug allergies

Medications: None

Family History: Mother deceased due to myocardial infarction, which occurred at age 36

Social History: Denies tobacco, ethanol, or illicit drug use; works as an airline attendant; history of unprotected anal intercourse with male partners

Physical Exam: Blood pressure 121/72; heart rate 68; respirations 20, temperature 97.7

General: Thin male in no distress

Head, Eyes, Ears, Nose and Throat: Normocephalic, atraumatic; mild conjunctival pallor; right retinal exam revealed perivascular sheathing with areas of necrosis; mild oropharyngeal thrush

Neck: Supple; no lymphadenopathy or thyromegaly

Chest: Clear to auscultation bilaterally

Cardiovascular: Regular rate and rhythm; no murmurs, rubs, or gallops; no jugular venous distention or edema

Gastrointestinal: Nondistended; normal bowel sounds; soft, nontender; no hepatosplenomegaly

Genitourinary: No genital or scrotal lesions

Skin: Warm and dry; healed zoster rash on right maxillary distribution and bridge of nose

Neurologic: Alert and oriented x3; right ptosis; right pupil sluggishly responsive to light and accommodation; L pupil normal; extraocular motion normal without nystagmus; other cranial nerves intact; cerebellar function normal; reflexes 1+, symmetric; Babinski absent; sensory intact; 4/5 motor of right arm and leg, all others 5/5; ataxic gait with falling to the right

Lab data:

WBC 6.6 (57 S, 2 band, 21 L); Hgb 12.3; Hct 39; PLT 432; Na 130; K 4.8; CL 95; HCO3 27; BUN 11; Cr 0.9; Glu 119; Ca 8.8; AST 437; ALT 747; GGT 126; Alkp 127; TB 1.4; Alb 2.6

Uric acid: 1+ protein

Lumbar puncture: 22 cm H2O pressure; Glu 9; TP 175; WBC 230 (58 P, 37 L); no xanthrochromia; no RBCs; Gram, India ink, and AFB stains negative

Radiology:

Chest radiograph normal

Head CT with and without contrast: A hypodense lesion in the left internal capsule extending into the inferior lentiform nucleus; an additional hypodensity in the posterior limb of the right internal capsule and in the right inferior lentiform nucleus; no abnormal enhancement; normal ventricles

Brain MRI: Diffusion weighted series demonstrates focal restraint of diffusion within the genu and proximal segment of the posterior limb of left internal capsule, the left cerebral peduncle and in the left temporal lobe just anterior to the temporal horn; prominent perivascular spaces; no intracranial hemorrhage

A test was performed and a diagnosis made...

The Problem

What is the likely diagnosis?

What diagnostic tests would you order?

Discussion

Feel free to discuss this case with others. You can monitor or join in the Medscape discussion at http://www.medscape.com/px/discussions/29d516f3.

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