52 male with altered sensorium secondary to HIV encephalitis

 A 52 years old male,resident of meerpet,Hyderabad,who used to work as a clerk in Bank of India society for 20years and stopped his work as a clerk as the bank was merged with another bank and now working in a catering team along with his brother since 10years(cutting vegetables was his work),was brought to casuality with complaints of Generalised weakness since 15 days

Unable to speak since 3 days

Deviation of mouth to right side since 3 days

Fever since 1 day

HOPI:

He was apparently asymptomatic till,2008 and then one day he had his brush and then while he was sitting and  drinking coffee he Suddenly fallen back with involuntary moments of upperlimb and lowerlimbs for 6minutes and there is no uprolling of eyeballs,no frothing,no involuntary micturition and defecation at that time and had loss of consciousness and persistent for 1 day,and at that time was diagnosed as HIV positive,started on medication since then..

His wife and children were tested and were negative..

And 12 years ago while he was walking on a road,the children who were playing roadside the stick/sand,came and accidentally fallen into the pt left eye and as the patient rubbed it ?cornea got eroded,and there is a loss of vision since then..

And since 6 months his working hours decreased,previously used to work for 8hrs in a day,soon which gradually reduced to 1hr in 5 mnths and completely stopped working since 1 and half month,and used to get irritated when he was asked to work by his brother and tell that he was having weakness and getting fatigued easily..

And he had diffuse,dull dragging type of headache and dragging pain of both upper limbs and lowerlimbs which were continuous and so was taken to hospital and got admitted for 1 week and got discharged and 15 days ago as he had decreased apetite and decreased responsiveness was again taken to govt hospital and as they didn’t like the atmosphere they went to prvt hospital and in a stay of 3 days,their expenses reached 4lakhs and so they came here for further management..

Fever,high grade,continuos,relieved on taking medication..

  cough when presented to hospital,not associated with sputum,more at night times..

No history of yellow discolouration of urine and eyes,No Vomitings,loose stools ,pain abdomen .

Past history:

K/C/O retroviral disease since 2008,used medication till 2015,and stopped since then as he had feeling of well-being and he has no othet complaints,asked to resume the ART 1mnth ago but he didn’t as he was not willing to take such big tablet,and now was on medication since 2 days(Tab.Doltugravir+lamivudine+Tenofovir 50+300+300mg)

Not a k/c/o,Diabetes,hypertension,Tb,CAD,CVA..

Daily routine;

Since 10 years,he used to getup at 7 am,freshup goes to work eats idli,dosa,poori as breakfast,avoids non veg as he don’t like and at the maximum their work ends at 4pm and after which he used to drink daily and look into his phone and have dinner and sleeps at 10pm..

He don’t go to cook in catering as he is scared of fire..

Personal history:

Loss of Apetite since 1 mnth

Weight loss history in 1 mnth(not checked exactly)

Sleep adequate

Chronic alcoholic (since 20 years,no limit ,90-180ml,depends)

Started on alcohol due to peer pressure..

Non smoker

General examination 

Pt is drowsy

Poorly built 

Temporal wasting +

Buccal pad of fat -

Brittle nails+

Hair sparse

Oral hygiene couldn’t be seen

Lip cracked

Skin appear dehydrated 

Weight:60kgs approx

No pallor,icterus,cyanosis,clubbing,lymphadenopathy and edema..

Left eye: cornea opacity +

Right eye :Normal ..

Vitals:

Bp:120/70mmHg

PR:102Bpm

RR:22cpm

RS:fine crepts in bilateral basal areas..

CNS:

Pt is drowsy 

GCS:

E2V2M4

Motor system:

Attitude limbs and lying by the pt side

Tone:increased in all four limbs 

Power:3/5(moving against gravity to pain)

Reflexes:

Right sided:Biceps,triceps,Supinator,knee and ankle 3+

Right plantar:Extensor

Left sided: Biceps,triceps,supination ,knee and ankle 3+

Plantar:flexors..

Right eye pupil reacting to light..

Cough reflex present.

Neck stiffness mild +

Signs couldn’t be elicited..

Sensory:moving all the limbs with pain..

Provisional diagnosis:

Altered sensorium secondary to encephalitis 

?HIV encephalitis..

Clinical images 

INVESTIGATIONS-

Serology -

HIV - Positive 

Blood for c/s -

No growth after 24 hrs of incubation

Sputum for AFB -

ZN stain - No AFB seen

Urine for culture and sensitivity-

No pus cells seen

No growth seen

Sputum for c/s-

Gram stain - Few pus cells ,no epithelial cells, few GNB seen

ZN stain - No AFB seen

MRI PLAIN-

E/o hyperintense signal on DWI/FLAIR / ADC noted on b/l corona radiata b/l genu of ant corpus collasum b/l thalamus b/l basal ganglia b/l midbrain pons and b/l cerebellar peduncles and b/l frontal regions 

Features suggestive of Subacute infracts

MRI CONTRAST-

Multiple ring enhancing lesions in pons midbrain b/l striatocapsular regions left frontal lobe and rt cerebellar hemisphere with extensive edema in the above areas 

f/s/o Neurotoxoplasmosis/Neurotuberculosis