A 47-year-old Hispanic woman with severe headaches of 1 month’s duration presents to the emergency department (ED). The pain encompasses the entire head, is constant and crushing (10 on a scale of 1 to 10), and has progressively worsened. Over-the-counter NSAIDs have provided no relief. She also reports associated photophobia, nausea, and vomiting that interfere with her daily activities, as well as night sweats, fever, and a 15-lb weight loss during the past month. For the past 3 days, she has had left-sided weakness that has reduced her ability to walk or hold a cup in her left hand. An MRI scan obtained 1 week before presentation at the ED showed multiple ring-enhancing lesions with impending uncal herniation (A).

The medical history includes migraine headaches for the past 6 years and idiopathic thrombocytopenic purpura during pregnancy 25 years earlier. The patient is married, has 3 healthy children and 4 cats, smokes cigarettes and drinks alcohol on occasion; she denies illicit drug use. Six months ago, she traveled to Honduras.

The patient is lethargic, incoherent, and unable to follow commands. Vital signs are normal. Cranial nerves are grossly intact. Sensation to pain, temperature, proprioception, and vibration is intact bilaterally. Motor strength is 4/5 on the left, 5/5 on the right. Reflexes are 2+ bilaterally. Toes are down-going bilaterally. The remainder of the physical findings are unremarkable.

A CT scan of the head reveals several irregular lesions in both cerebral hemispheres and in the right cerebellar hemisphere, with surrounding edema (B).

 

 

 

What do you suspect—and how will you confirm the diagnosis?

(answer on next page)

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