38 year old woman with HIV/AIDS and altered mental status

The patient is a 38 year old African-American female with a complicated past medical history including HIV/AIDS (CD4 count of 3, and a viral load of 750,000) and a recent hospitalization for confusion, lethargy and seizure who presented to the Moore Clinic for follow up care.

Her family reported a decline in cognitive function including confusion and forgetfulness over the past 1-2 months. She also had increasing lethargy for 1-2 weeks. Because of declining responsiveness she was taken to an outside hospital. Her workup at the outside hospital included induced sputum which was negative for PCP and negative for AFB x 2. CT scan of the head revealed at least 6 ring enhancing lesions in the brain. CT scan of the abdomen and pelvis showed only uterine fibroids. She had one seizure in the outside hospital. She was given Decadron and fluconazole for the brain lesions and phenytoin for the seizure and was discharged to hospice where she stayed for one day. Her family brought her to the Moore Clinic for a more definitive evaluation and she was admitted to The Johns Hopkins Hospital.

The patient was found to have HIV approximately 1 year before admission, likely due to heterosexual transmission. She had no history of IVDU. At that time her CD4 count was 9 with viral load of 750,000 copies/ml. She was not placed on HAART because of ongoing crack cocaine use. She was referred for drug treatment but she quit after one week. She had followed-up with the Moore Clinic intermittently and often missed appointments.

HIV/AIDS
Multiple hospitalizations for Candida esophagitis, asthma exacerbations and herpes outbreaks
Asthma
Chronic bronchitis
Allergic sinusitis
Neutropenia
Anemia
Herpes simplex virus infection
Trichomonas infection
Pelvic inflammatory disease
Chlamydia infection
Gonorrhea
Pyelonephritis with pregnancy
Right cerebrovascular accident with postpartum hypertension, no residual deficit, (1980s)

The patient's family history is notable for her father deceased many years ago from cirrhosis and her mother who died of "lung disease". The patient has four children. One son has asthma and the other has bone disease. The patient has one brother who is ill from an unspecified disease. Her half sister has a significant respiratory illness and two half siblings who are healthy.

The patient is disabled and lives with her brother. She has no income or health insurance. She previously worked as a cashier, telephone representative and janitor. She completed the 11th grade. She has a long history of and active polysubstance abuse including alcohol for 35 years, crack cocaine for 16 years and tobacco for 19 years. Neither she nor her family has any pets. They report no travel outside Baltimore.

Dilantin 300 mg q.day, decadron 4 mg bid, fluconazole 100 mg q day.

No known drug allergies.

As above and incontinence. Review limited since patient was unable to respond to questions.

• Weight: 99 lbs Height: 73 inches T: 99.3 BP: 91/62 P: 129 SaO2: 88% room air
• General: Chronically ill, severely catechetic African-American female.
• HEENT: Sclera anicteric. Conjunctiva pale. Pupils: left is reactive to light and the right is sluggish. Patient unable to follow commands to evaluate extraocular movements. No lymphadenopathy.
• CV: Tachycardic, regular rhythm, S1, S2 normal with no murmurs, rubs or gallops.
• Lungs: Rhonchi throughout, no wheezes. On oxygen 3L nasal canula.
• Extremities: Unremarkable, no cyanosis, clubbing, or edema.
• Neurologic exam: Deep tendon reflexes +2 at the brachial, radial, and patellar sites. Patient unable to respond to verbal commands other than intermittent squeezing with the right hand. The left arm is flaccid. The right and left leg are not flaccid; however, the patient cannot follow commands to use her legs. She cannot stand.
• Skin: Herpetic lesions over vulva.

On Admission:

• Na 132; K 5.3; Cl 93; CO2 19; BUN 39; Cr 1.3; Glucose 104; Calcium 10.1; Phosphate 6.5; Magnesium 2.1; TP 7.8; Albumin 3.9; TBili 0.4; AST 41; ALT 75; Alk Phos 67; Anion Gap 25
• Lactic Acid: 1.7
• WBC 11,380; RBC 4.84; Hemoglobin 14.0; Hct 42.9; MCV 88.6; Platelet 308
• ABG: pH 7.42; pCO2 29; p02 134; HC03 calculated 18
• PT 12.9, aPTT 22.4; INR 1.2
• Blood and CSF Cryptococcal Antigen: negative
• Toxoplasma IgG: negative
• CSF: Cell Count: 2 cells (100% mononuclear cells); Protein 64; Glucose 74; Gram Stain: No neutrophils and no organisms seen.

Chest X-ray (admission): Many scattered nodular infiltrates bilateral lungs.

Brain CT (Admission): MULTIPLE FOCI OF DECREASED ATTENUATION ARE IDENTIFIED IN THE DEEP WHITE AND GRAY MATTER INCLUDING THE RIGHT FRONTAL LOBE, LEFT FRONTAL AND SUB INSULAR REGION EXTENDING TO THE INTERNAL AND EXTERNAL CAPSULES, LEFT THALAMUS, RIGHT BASAL GANGLIA, AND LEFT POSTERIOR TEMPORAL-PARIETAL REGIONS. THESE HAVE THE APPEARANCE OF VASOGENIC EDEMA SURROUNDING UNDERLYING MASSES.

MRI Brain (Hospital Day 2) (IMAGE 1): INUMERABLE MASSES ARE IDENTIFIED THROUGHOUT THE INFRATENTORIAL AND SUPRATENTORIAL BRAIN, INCLUDING A 2.6 CM (ENHANCING PORTION) IN THE LEFT CEREBELLUM, NODULAR RIM ENHANCING 2.5 CM NECROTIC MASS CENTERED IN THE LEFT CAUDATE NUCLEUS, AND AN AT LEAST 2.4 CM VAGUELY ENHANCING MASS IN THE RIGHT PARAMEDIAN FRONTAL REGION. SOME OF THESE LESIONS DEMONSTRATE RIM ENHANCEMENT, SOME WITH PATCHY AND ILL-DEFINED ENHANCEMENT, AND IN SOME THERE IS NO SIGNIFICANT ENHANCEMENT. CORRESPONDING TO THESE MASSES THERE ARE MULTIPLE AREAS OF T2 HYPERINTENSITY IN THE BILATERAL CEREBELLAR HEMISPHERES, RIGHT PONS AND CEREBRAL PEDUNCLE, RIGHT THALAMUS, BILATERAL BASAL GANGLIA, AND IN ALL LOBES---SOME INVOLVING THE CORTICAL GRAY AND MOST INVOLVING THE SUBCORTICAL WHITE MATTER. A RIGHT PARAMEDIAN FRONTAL MASS HAS A SMALL CENTRAL T2 DARK AREA PROBABLY REFLECTING OLD HEMORRHAGE OR CALCIFICATION. THE VENTRICULAR SYSTEM IS PROMINENT. THE LEFT FRONTAL HORN IS COMPRESSED BY SUBJACENT MASS AND NEARLY EFFACED. NO MIDLINE SIGNIFICANT SHIFT. NORMAL FLOW VOIDS ARE VISUALIZED IN MAJOR INTRACRANIAL VASCULAR TERRITORIES. NO SIGNAL ABNORMALITY IS IDENTIFIED ON THE DIFFUSION WEIGHTED IMAGES AND CORRESPONDING ADC MAP TO SUGGEST AN ACUTE INFARCT.

3-D MR ANGIOGRAM OF THE CIRCLE OF WILLIS DEMONSTRATES NORMAL FLOW-RELATED ENHANCEMENT OF THE INTRACRANIAL CIRCULATION. NO ANEURYSM OR STENOSIS IS IDENTIFIED.

Chest CT (Hospital Day 3) (IMAGE 2): Pulmonary embolus in the right lower lobe pulmonary artery. Multiple bilateral pulmonary nodules, a few which are wedge shaped and near the end of vascular structures. Bilateral lower lobe atelectasis.

The patient was admitted to the Intermediate Care Unit and started on broad antibiotics. On second day of admission the patient was found to have a dilated, unresponsive left pupil. An MRI was performed (above). She developed worsening oxygenation and hypotension and a chest CT was performed (above). Her condition continued to worsen and she developed worsening hypotension despite fluid resuscitation. She became unresponsive without spontaneous movements. After discussion with the family, comfort care was instituted and the patient expired on Hospital day #5.

What are possible and most likely cause(s) of her cognitive decline?

What potential co-morbidities was she at risk for due to her advanced HIV?