Diagnostic Challenge: 23-Year-Old With Seizures and Tongue Pain

A 23-year-old man is brought to the hospital by his family with complaints of malaise, fatigue, a 22-lb (10-kg) weight loss, and a 10-month history of diminished appetite.


Challenge
A 23-year-old man is brought to the hospital by his family with complaints of malaise, fatigue, a 22-lb (10-kg) weight loss, and a 10-month history of diminished appetite. He also complains of painful tongue erosions which are covered with a white, creamy exudate. Three days after admission to the hospital, the patient’s mental status progressively declines, evolving from drowsiness to confusion. He is eventually found by the nursing staff to be stuporous. Soon afterwards, the patient experiences generalized tonic-clonic seizures and sudden dense left hemiparesis.

At the time that the patient develops altered mental status, his family states that he has also been having increasingly severe headaches without neck stiffness or fevers. The patient has not had any known trauma. He does not have any known risk factors for tuberculosis nor has he had any ill contacts. He has no previously diagnosed medical conditions and has not been taking any medications. No significant family history is reported. His social history is remarkable only for sexual relationships with men.

Physical Examination and Workup

Upon physical examination, during the development of his altered mental status, the patient’s temperature is 97.7°F (36.5°C), his pulse is regular at a rate of 100 beats/min, his blood pressure is 100/50 mm Hg, and his respiratory rate is 16 breaths/min. A normal S1 and S2 are auscultated, with no murmurs or rubs. His lungs are clear in all fields. Palpation of the abdomen reveals no tenderness, masses, or enlargement of the liver or spleen. His mucous membranes are pale and the tongue has diffuse, creamy white exudates, which, when scraped, leave a bleeding, ulcerative surface. The neurologic examination reveals stupor, a dense left-sided hemiparesis, seventh cranial nerve palsy, and an extensor plantar response on the left. No pupillary abnormalities are noted.

Laboratory testing is performed and includes a complete blood count (CBC) that reveals anemia with a hemoglobin concentration of 9.4 g/dL (94 g/L) and a hematocrit of 29% (0.29). His white blood cell (WBC) count is within the reference range, except for 63% (0.63) lymphocytes. The erythrocyte (globular) sedimentation rate is elevated at 62 mm/hr. Complete metabolic panel findings, including electrolytes and liver enzymes, are normal. Cerebrospinal fluid is not initially obtained because of a concern for increased intracranial pressure.

A CT scan of the brain is performed (Figures 1-4).

Figure 1: Figure 2: Figure 3:Figure 4:

Based only on these findings, which is the most likely diagnosis? (Hint: The patient’s social history is critical to the diagnosis.)

  • Central nervous system (CNS) toxoplasmosis
  • Glioblastoma multiforme
  • Subarachnoid hemorrhage
  • CNS lymphoma

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