Case of the Month - January 2012
A 40-year old immigrant from Democratic Republic of Congo
presented to a Cape Town hospital following a seizure. He had
flown to South Africa 1 year previously from his home in Kibibi
village, Bandudu, DRC and had been well until 4 months prior to
admission. His friend had noted a slowing of his thought
processes, and increased somnolence.
One week prior to admission, he developed fever and shivering. Examination reportedly revealed a thin man with slowed affect, a temperature of 38.4oC and firm posterior cervical lymphadenopathy. Chest x-ray showed bilateral hilar adenopathy, but no pulmonary infiltrate. 4th generation HIV ELISA – negative.
Lumbar puncture:
Lymphocytes 49, polymorphs 0, red cells 0
Protein 0.77, glucose 4.2 (blood glucose 6.1)
Cryptococcal latex antigen test – negative
Acid fast bacilli - negative.
FTA and VDRL – negative
He was started on empiric therapy for TB meningitis with Rifafour (rifampicin, isoniazid, pyrazinamide and ethambutol) plus prednisone.
One month later, he was transferred to a tertiary level hospital, having failed to respond to therapy. On presentation, he was somnolent, his speech was markedly slowed and he was disorientated in time, place and person. He had a Parkinsonian tremor of the upper limbs, but no other focal neurological deficit. Posterior cervical chain lymphadenopathy was present and there was no change in his chest x-ray appearance. Ultrasound scan of the abdomen revealed retroperitoneal adenopathy and a bulky spleen measuring 12.5cm
Repeat lumbar puncture showed 20 lymphocytes, 14 polymorphs, protein 0.57 and glucose of 2.7.
One week prior to admission, he developed fever and shivering. Examination reportedly revealed a thin man with slowed affect, a temperature of 38.4oC and firm posterior cervical lymphadenopathy. Chest x-ray showed bilateral hilar adenopathy, but no pulmonary infiltrate. 4th generation HIV ELISA – negative.
Lumbar puncture:
Lymphocytes 49, polymorphs 0, red cells 0
Protein 0.77, glucose 4.2 (blood glucose 6.1)
Cryptococcal latex antigen test – negative
Acid fast bacilli - negative.
FTA and VDRL – negative
He was started on empiric therapy for TB meningitis with Rifafour (rifampicin, isoniazid, pyrazinamide and ethambutol) plus prednisone.
One month later, he was transferred to a tertiary level hospital, having failed to respond to therapy. On presentation, he was somnolent, his speech was markedly slowed and he was disorientated in time, place and person. He had a Parkinsonian tremor of the upper limbs, but no other focal neurological deficit. Posterior cervical chain lymphadenopathy was present and there was no change in his chest x-ray appearance. Ultrasound scan of the abdomen revealed retroperitoneal adenopathy and a bulky spleen measuring 12.5cm
Repeat lumbar puncture showed 20 lymphocytes, 14 polymorphs, protein 0.57 and glucose of 2.7.
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