AM is a 32-year-old female patient; she was admitted in our hospital on 10TH May 2011 with complains of right hemiplegia of recent onset.
AM was borne mentally retarded, but she was not epileptic.
She developed symptoms of partial convulsions 3 months ago. At the beginning the twitching involved only the right upper limb.
Unfortunately, the family did not take the convulsive disorder seriously, and the condition became worse up to 2 months ago when the patient developed paralysis of the right side of the body. At the moment, apart from the hemiplegia, AM complains of tonic-clonic generalized convulsions (Jacksonian seizures).
Our first diagnosis was of C.V.A. (cerebro-vascular accident) or S.O.L. (space occupying lesion). We were also thinking of possible brain haemorrhage.
AM was presented to the physiotherapist, who strongly recommended a CT scan of the brain. Even before being able to do the scan, we tested the patient for HIV, because we noted a full haemogram with total lymphocyte count of 500. Unfortunately the HIV test was positive, and, according to the presence of the above symptoms, together with a total lymphocyte count below 1100, we have classified the infection as WHO stage IV.
The staging made us decide on immediate starting of ART (anti retroviral treatment).
The fact that AM is mentally disabled has made the counseling practically impossible, and we have therefore decided to inform the parents.
Of course they were shocked about the news of immunosuppression, because they were wondering if somebody could have violated her daughter, taking advantage of her mental condition.
We tried to calm them down, considering the fact that the patient was transfused in the past.
Thereafter we sent her for CT scan and we got a surprising finding; the report in fact reads as follows: “extensive hypodense lesion in the left temporal region with a small hyperdense lesion at the centre, seen on IV contrast. Slight mass effect. Conclusion: suggestive of tuberculoma of the left temporal region with a lot of associated oedema”.
The poor AM has therefore got a very rare form of TB, which is to be considered as an opportunistic infection due to full blown AIDS.
She is now on treatment with ART (AZT, 3TC, EFV), together with TB treatment (2RHZE, 4RH); she is also on prophylaxis for PCP with Septrim 960 mg OD.
For the epileptic disorder we have chosen to use VALPROATE at the dose of 20 mg/kg.
We still don’t know if the above treatment, associated with physiotherapy, will be able to make the hemiplegia improve.
I have nevertheless presented this short case report, because in Africa we can still find diseases which are unknown or extremely rare in the West. The HIV pandemic is also contributing to strange presentations of known illnesses. Therefore the volunteers coming to help us must try to broaden the spectrum of their differential diagnosis, considering both the tropical pattern and the AIDS burden.
On a totally different level, when I am in front of AM, I feel extremely confused, because I realize that she doesn't deserve all the burden of misfortunes the life has given her. Maybe she is HIV positive because somebody without conscience has repeatedly raped or abused her... and she has the mind of a small child.
I also feel so lucky and I promise myself always to be contented of what I have, because in the world there are people who suffer much more than me.
Dr. Br. Giuseppe Gaido
Nessun commento:
Posta un commento