Justice
Forum Fanatic
Topics: 101
Posts: 1,972
|
First of all: the Qns I am posting are neither UW nor NBME. Correct answers will be posted in 7 days to enable maximal number of colleagues to test their knowledge.
A 36-year-old man who has been HIV positive for approximately 10 years is brought to the emergency department after a witnessed seizure. He had been receiving antiretroviral medications until approximately 5 years ago, when he dropped out of care. The patient has taken no medications since that time and has no history of AIDS-related problems. Family members report that he has had some memory loss and unusual behavior for the past 2 weeks.
On physical examination, he is confused and disoriented but does not appear to be chronically ill. Vital signs are normal. An MRI scan of the head shows a single ring-enhancing lesion within the left cerebral hemisphere arising from the basal ganglia with significant mass effect, including midline shift.
The patient is hospitalized, and high-dose dexamethasone is begun. The following day, his CD4 cell count is 17/μL. Toxoplasma 1gM titer is negative, andToxoplasma lgG titer is positive. Cytomegalovirus 1gM titer is negative, and cytomegalovirus lgG titer is positive.
Which of the following is most appropriate for initial management of this patient?
A. Treat empirically for toxoplasmic encephalitis
B. Order stereotactic biopsy of the brain lesion
C. Perform lumbar puncture for cerebrospinal fluid culture and cytologic studies
D. Treat empirically for cytomegalovirus encephalitis
E. Treat empirically for bacterial brain abscess
___________________
Don't live in a town where there are no doctors
|
| dr.wad
Forum Senior
Topics: 3
Posts: 335
|
B.....>>>.hodgkins lymphoma.
the second most common brain mass in HIV pt , after toxo.
not toxo >>>> negative IgM ( the pt presented for 2 weeks )
|
| sandra
Forum Guru
Topics: 200
Posts: 468
|
B..lymphoma
___________________
You become what you think you are!
|
| fafa
Forum Newbie
Topics: 0
Posts: 11
|
what are you saying guys
indefinitely it is Toxo
Don`t u remember that Toxo isn`t recently acquired in HIV +ve and its lesion is just due to reactivation of previous exposure
so You gotta treat Toxo empirically
If things didnt become better then you biopsy lesion and assume that it it s Lymphoma
|
| drems
Forum Newbie
Topics: 0
Posts: 1
|
A. Treat for toxo then rpt scan after 2 wks. If no shrinkage of leision then do a biopsy.
|
| cool doctor
Forum Junior
Topics: 1
Posts: 226
|
A
|
| Markus2009
Forum Senior
Topics: 9
Posts: 189
|
Agree with A
the immnunoglobulines pattern in such as immunodeficient patient means nothing so I will treat empirically for toxoplasmosis and if there is no improvement then i will go with biopsy to rule/out cerebral lymphoma.
|
| Justice
Forum Fanatic
Topics: 101
Posts: 1,972
|
The correct answer is A
The dilemma in managing this AIDS patient, who is at risk for all major AIDS-related complications, is that he has a single mass lesion of the brain, whereas at least two thirds of patients with toxoplasmic encephalitis have multiple ring-enhancing lesions. His presentation is therefore somewhat atypical. However, he does have other features that are more typical of toxoplasmosis: 1) the lesion arises from the basal ganglia, and 2) serologic studies indicate past infection consistent with reactivation of quiescent infection that occurs with AIDS-related immunodeficiency. The most appropriate management is to treat this patient presumptively for toxoplasmosis with pyrimethamine plus either sulfadiazine or clindamycin and to monitor his clinical and radiographic treatment response. Biopsy of the lesion is indicated only if he does not respond to initial treatment.
Primary central nervous system lymphoma is a possible diagnosis for which lumbar puncture can be done to detect Epstein-Barr virus DNA. This test is reported to be both sensitive and specific for lymphoma in this setting. However, lumbar puncture is contraindicated in this patient because of the significant mass effect seen on the MRI scan. Cytomegalovirus encephalitis would not present as a mass lesion, and a bacterial brain abscess is no more common in AIDS patients than in other hosts. If his CD4 cell count were considerably higher than 200/μL, a bacterial abscess would be more likely.
___________________
Don't live in a town where there are no doctors
|
|
| |
| | | | | | | | |
