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Washington University Experience | NEOPLASMS (HEMATOLYMPHOID) | Lymphoma, immune-compromised | 10A0 Case 10 History
Case 10 History ---- The patient was a 51 year old male with an 8 year history of HIV infection manifested by HIV cardiomyopathy, Kaposi's sarcoma, treated syphilis, hepatitis, peripheral neuropathy, possible myopathy, and AIDS dementia. The patient was admitted with a 3 week history of cough, poor oral intake, and personality changes. He had been started on oral antifungal therapy four days previously for a right lower lobe infiltrate on chest Xray and a positive sputum culture for Aspergillus. However, he had not improved on this regimen. Admission examination revealed a cachectic man with a low grade fever. Cranial nerves were intact. Motor exam showed a mild, diffuse weakness and increased muscle tone. Sensory exam revealed a dense distal sensory loss in a stocking-glove distribution. Snout and palmomental reflexes were present. There was a Babinski sign on the left. The gait was slow and shuffling. Initial laboratory workup revealed a CD4 count of 39, normal CSF and minimal elevation of toxoplasmosis titers. An MRI of the brain showed 2 ring enhancing lesions with surrounding edema, the larger in the right frontal lobe and the smaller in the left frontal central area. He was treated empirically for toxoplasmosis but continued to deteriorate with a worsening encephalopathy and the development of a mild left hemiparesis. A biopsy of his lung lesion was non-diagnostic. A stereotactic brain biopsy was performed of the right frontal lobe lesion and was most compatible with lymphoma. A few days later the patient developed a generalized tonic clonic seizure, and thereafter continued to have frequent focal seizures involving his left upper extremity. A repeat head CT scan showed worsening edema and mass effect with possible right to left cingulate herniation. Two days following the onset of his seizures he was noted to develop progressively worsening Cheyne-Stokes respirations with apneic episodes and finally expired from respiratory arrest. ---- At autopsy the weight of the unfixed brain was 1500 gm.
