Solution to "30-Year-Old Male With Right-Sided Weakness"

Robert M. Centor, MD

Disclosures

April 12, 2006

This is the solution to a case we presented recently. You may review the case here.

This case of a young man presenting with a new stroke represents a very interesting differential diagnosis. When I first reviewed this case, I considered the possibilities of meningitis in a patient who was HIV-positive.

My first differential list included listeria meningitis, cryptococcal meningitis, TB meningitis, CMV meningoencephalitis, and toxoplasmosis. I immediately excluded toxoplasmosis because the CT findings were not consistent. Toxoplasmosis presents as a "ring enhancing" lesion -- ie, a mass effect. Our patient's CT suggests multiple strokes, but no mass effect.

In considering listeria, I found that when listeria caused neurologic deficits, it also presented with a mass effect. The CSF results did make sense for listeria, but the CT scan made that diagnosis unlikely.

Cryptococcal meningitis has a different clinical presentation. It often presents with headache and confusion. I could not find acute onset of stroke as a presentation of cryptococcal meningitis.

TB meningitis remained on my differential. The CSF findings fit perfectly. However, the CT scan generally shows meningeal enhancement and hydrocephalus. Although I could not completely exclude TB meningitis, I relegated that diagnosis to third place.

CMV meningitis presents as dementia, not stroke. The CSF findings and the CT scan do not fit CMV.

At this point, I rethought the case. Although the patient is HIV-positive, he had a normal CD4+ cell count 3 months previously. Thus, I must consider other diagnostic possibilities.

I focused on the oculomotor (third nerve) palsy and the strokes. The CT suggested several strokes, while the MRI documented a recent stroke in the left side (causing the right-sided symptoms).

Although one might consider a wide variety of etiologies at this point, I quickly narrowed my thoughts to varicella zoster and syphilis.

Given his recent episode of varicella zoster, he had a possibility of an unusual complication: varicella zoster-associated cerebral angiitis. This complication generally occurs after ophthalmic zoster. Although the maxillary nerve is close, I could not find any cases of maxillary nerve zoster leading to stroke. Additionally, the stroke of zoster-associated cerebral angiitis generally occurs on the contralateral side from the zoster. Our patient had both right-sided zoster and right-sided weakness. Reluctantly, I made this possibility the second most likely.

Neurosyphilis can present in many ways. I considered the possibility that he had a specific variety of neurosyphilis: meningovascular syphilis. He clearly has risk factors for syphilis (sexual history). Meningovascular syphilis can definitely present with strokes in young patients at risk. I could find nothing in the case to exclude this possibility, and I found reasonable objections to every other possibility. Thus, I used the famous Sherlock Holmes technique: "It is an old maxim of mine that when you have excluded the impossibility, whatever remains, however improbable, must be the truth."

In fact, the patient had neurosyphilis documented by CSF VDRL. He was treated with antibiotics and had a complete neurologic recovery.

Incidentally, his liver enzyme elevations were explained by acute viral hepatitis B (another disease that his risk factors would suggest).

Read and participate in the discussion of this case here, and watch for another new case soon.

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