Multifocal strokes in a 56-year-old man with HIV infection

Abstract

A 56-year-old man presented with a oneday history of vomiting, vertigo and blurred vision in both eyes preceded by a three-week history of fever, night sweats and a 5-kg weight loss. He had no recent history of travel or contact with sick people. His past medical history was notable for untreated HIV infection diagnosed eight months previously, after treatment for presumed Pneumocystis jirovecii pneumonia. At that time, his CD4 count was 0.072 × 10 9 /L. He was immune to hepatitis B virus infection secondary to a previous natural infection, and he had remote idiopathic retinal vasculitis. He had had chickenpox as a child. There was no history of hypertension, diabetes mellitus, smoking, dyslipidemia, atrial fibrillation or cardiac disease. He denied intravenous drug use.On examination, the patient was afebrile, his blood pressure was 133/83 mm Hg, and his heart rate was 57 beats/min and regular. He was somnolent but rousable and answered questions appropriately. Findings on cardiovascular, respiratory and abdominal examinations were normal. Neurologic examination showed bilateral eye deviation to the right as well as horizontal, vertical and torsional nystagmus in primary position, which worsened with rightward gaze. There was rightsided miosis but no ptosis. Speech and swallowing were normal. Muscle tone, power and reflexes were normal. There was decreased sensation to pinprick in the right cheek and the left arm and leg. The patient had marked ataxia in his right arm and leg (appendicular ataxia). Dermatologic examination revealed several crusted skin lesions distributed over his body, with a single vesicle overlying his right zygoma. There were no peripheral findings of infective endocarditis.The patient's leukocyte count was 2.4 (normal 4.0-11.0) × 10 9 /L, hemoglobin A 1C concentration 6% (normal 4%-6%) and low-density lipoprotein cholesterol 2.76 mmol/L. Blood cultures for bacteria were negative. Tests of the patient's serum were negative for syphilis and cryptococcal antigen. The erythrocyte sedimentation rate was 41 (normal 0-10) mm/h.Magnetic resonance imaging of the brain showed small acute infarcts in the left frontal cortex and deep white matter (the territory supplied by the left middle cerebral artery) and in the right lateral medulla and right cerebellar hemisphere (the territory supplied by the right posterior inferior cerebellar artery) (Figure 1