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Chest pain, increasing fatigue, generalized joint pain, headache and problems with balance and memory for 5-6 weeks duration
History of Present IllnessThe patient is a 64-year-old Indian male who presented to the emergency department with multiple complaints. He had chest pain of five to six weeks in duration that was continuous, non-radiating and worsened when sleeping on his side. It caused him to feel short of breath and have dyspnea on exertion. The pain was not relieved with rest or with antacids. A dipyridamole myocardial perfusion study did not show evidence of ischemia.
He also reported fatigue and anorexia during the same period of time. His wife reported that he slept about twenty-two hours a day for the three weeks prior to admission. During the six weeks prior to admission he also had a decreased food intake with ten pound weight loss. He denied any dysphagia, nausea, vomiting, diarrhea, or abdominal pain. He had recently developed diffuse joint pain for which he was treated with Celebrex. There was no swelling or redness of the joints. He denied night sweats but did report subjective fevers.
For three days prior to admission he had complaints of headache. The headache was throughout the day, was bilateral and non-pulsating. He denied photophobia or blurred vision. He had also recently developed intermittent problems with his balance when walking, and with his memory. His wife said that he seemed disoriented.
Past Medical HistoryAllergic rhinits, chronic constipation, obstructive sleep apnea, and schistosomiasis as a young adult.
Past Surgical HistoryCholecystectomy Inguinal hernia repair
Family HistoryNo history of cancer
Daughter with history of treated tuberculosis 10 years ago
Born in India and lived there for twenty six years before coming to the United States. He traveled throughout the United States and to Puerto Rico for his job as a civil engineer. No history of tobacco or ethanol abuse and his family reports that he has one to two drinks of alcohol per year. He does not recall skin tests for tuberculosis.
Medications
Advair
Allegra D
Astelin
Celebrex
Metamucil
Milk of magnesia
NKDA
Review of SystemsSee HPI
Physical Exam on Admission- The patient is a thin male in no acute distress. There is some temporal wasting.
- Vital signs: T=36.5 C, HR=60, RR=20, BP=136/92.
- Head and Neck: Sclerae anicteric, oropharynx clear, no lymphadenopathy, no thyromegaly. Fundoscopic examination normal. Neck supple.
- Lungs: Clear to ausculatation
- Cardiovascular: Regular rate, no murmurs, rubs or gallops
- Abdomen: Soft and protuberant. Bowel sounds present.
- Extremities: No edema. Joints and extremities were diffusely tender but without redness, effusion, or synovitis.
- Neurologic examination: no cranial nerve abnormalities, diffusely weak due to generalized malaise and pain. No focal motor or sensory deficits.
Initial routine chemistries were significant for low serum sodium, normal
potassium, low chloride and a high total protein.
Liver function tests were normal. Cardiac studies demonstrated normal creatine
kinase and troponin I.
PA chest shows diffuse involvement of both lungs with a profusion of very fine nodules (Image 1) .Closeup views of both lungs confirms the presence of a subtle but definite micronodular infiltration (Images 2-3). CT scans more clearly demonstrate the existence of a small nodular infiltrates in the lung parenchyma (Images 4-6).
Unenhanced computed tomography of the head demonstrated areas of edema in the left temporal and parietal lobe as well as in the right frontal lobe suggestive of infarctions or masses.
MRI showed at least six focal areas of abnormal increased signal intensity were seen in the right and left frontal lobes, the left anterior temporal lobe, the left occipital lobe and the right occipitoparietal lobe.
Clinical CourseThe patient developed worsening changes in mental status. A lumbar puncture was performed revealing 75 WBC with 75% neutrophils and 25% lymphocytes. Blood, urine, and CSF cultures were negative. Eventually he became unresponsive and was placed on mechanical ventilation. After 5 days of no improvement, care was withdrawn and he expired.
QuestionsWhat is your differential diagnosis for his signs and symptoms?
What diagnostic procedure would you suggest?
What was the most likely cause of death?
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