A 57 Year-Old Man with HIV Presenting with Severe Headache and Progressive Weakness

A 57 year-old man with HIV with undetectable viral load and CD4 count of 600, managed with antiretroviral therapy, presented to the hospital with severe neck pain, progressively worsening headache, and general malaise. In the emergency department (ED), his examination was non-focal with a normal mental status. Non-contrast head computed tomography (CT) was unrevealing. He was admitted for cardiac and neurologic evaluation. Neurology was consulted and found his examination to be unremarkable. They recommended MRI of his brain to evaluate his headaches; this revealed punctate foci of left hemispheric ischemia, primarily at the gray-white junction, leading to a stroke workup. Carotid duplex ultrasound revealed severe (70-90%) left carotid stenosis. Intracranial vessel imaging was not performed. On hospital day (HD) 1, he developed a fever to 39.2C and photophobia. This prompted concern for endocarditis, so TEE was performed and was unremarkable. On HD 2, he abruptly became unresponsive. Repeat head CT was unchanged. Routine EEG demonstrated diffuse slowing without focal or epileptiform activity. His mentation spontaneously recovered. Levetiracetam was empirically started. Three days later, a lumbar puncture was performed. CSF analysis demonstrated a lymphocytic pleocytosis (WBC 1435, 83% lymphocytes; RBC 147), elevated protein (641), normal glucose (50), and varicella zoster virus (VZV) polymerase chain reaction (PCR) positivity. Intravenous (IV) acyclovir and IV methylprednisolone were initiated. On HD 6, he developed respiratory distress and was intubated for hypoxic respiratory failure and transferred to the ICU. Several days after arrival to the ICU, he developed progressive weakness and areflexia. Weakness was initially present in his left lower extremity, then evolved to affect his left upper extremity and then right lower and upper extremity, respectively. On HD 13 and ICU day 7, he remained febrile, which prompted a chest CT to be obtained to evaluate for pulmonary embolism (PE). A small, bilateral proximal PE was discovered. He was heparinized and then transferred to our institution at the family’s request.