A 45-year-old patient
was admitted in our facility from 14th December 2012 to 17th
December 2012.
He was complaining
of headache, neck pains, dizziness, neck stiffness, burning abdominal pains.
He reported one
episode of nose bleeding one week before hospitalization. But there was never
bleeding in hospital.
Malaria slide
was positive and so it was the Widal test, both O and H antigens at a dilution
of 1:160.
HIV was tested
and found negative. Brucella antibody tests were negative. RBS 6.2 mmol/l.
At FHG (full
hemogram) there was nothing impressive: total WBC 9000/ml; LYMPH 12%, GRAN 80%;
HB 13.9 g/dl; PLTs 96000.
BP (blood
pressure) was borderline, ranging from 160/90 up to 160/95 while in pain.
We decided to
treat with iv Quinine (because of the positive malaria slide) and iv CAF [=
Chloramphenicol] (because of the elevated titration of antibodies
anti-salmonella).
The idea was to
consider the hypothesis of subarachnoidal hemorrhage and propose CT scan if
there would not be improvement.
But the patient
improved quickly on treatment and he was discharged without headache, without
neck stiffness and with normal BP.
There was
history of heavy drinking in the days previous to the admission. The patient
was also complaining of epigastric pains. A gastroscopy was suggestive of
hyperemic gastritis, and he was treated with omeprazole.
LFTs (liver
function tests) were done and they were within range.
On discharge the
BP was 120/80.
A stool test
before discharge was positive for amoeba.
The patient was
therefore discharged on oral quinine, oral paracetamol, oral CAF and oral
metronidazole.
But after a
while the headache recurred. There were no neurological signs of
lateralization, and the BP was within normal range.
There was no
fever.
Not knowing
exactly the cause of headache, we decided on CT scan and the result was really
surprising.
We were expecting
a negative imaging test, which would help us reassure the patient and maybe
orientate us towards a diagnosis of migraine.
But the computerized
tomography came up with an image like the one shown below.
It was a
tuberculoma of the brain, a condition quite rare considering the fact that the
patient is HIV negative.
Dr Bro Giuseppe
Gaido