CLINICAL CASE OF THE MONTH: A 31-Year-Old Man Who Presents with Speech Abnormalities.
A 31-year-old man with advanced human immuno-deficiency virus (HIV) infection presented to the emergency department with " altered mental status " (AMS) for two months and blurry vision for one day. The patient and his family began to notice that he would " stumble over words " while he spoke. Three weeks prior to presentation, he started calling people by the wrong name, and eventually, was unable to answer questions, properly identify objects or converse normally. Per family, he understood what was asked but could not express a proper response. On the morning of his admission, the patient complained that he could not see his girlfriend clearly, only her silhouette, prompting her to bring him to the emergency department. Review of systems was otherwise unremarkable, including no weakness or changes in gait or sensation. The patient was diagnosed with HIV seven years prior. He had only visited his HIV physician three times since 2007 and had never taken combination antiretroviral therapy (cART). Labs from clinic 40 days prior to presentation showed a total CD4 count of 6 cells/mm 3 (228-2290 cells/ mm 3), CD4 percentage of 2.4% (37-63%) and a viral load of 121,738 copies/ml. The plan at that time was to begin cART therapy once his HIV genotype was obtained. The patient had a past medical history of oropharyngeal candidiasis, pneumonia and herpes zoster. His medications at the time of presentation included azithromycin and trimethoprim/ sulfamethoxazole (TMP/SMX) for prophylaxis against op-portunistic infections. The patient continued to smoke, but denied any alcohol or illicit drug use. He was living at home with his girlfriend and had two daughters, one of whom was also HIV-positive. On presentation, vital signs included a temperature of 98°F, heart rate of 88 beats/min, respiratory rate of 16 breaths/min, blood pressure of 113/73 mmHg and an O 2 saturation of 100 percent on room air. He weighed 148 pounds with a body mass index of 21. The patient was in no acute distress and oriented to person, but was unable to accurately identify the time or place, stating " I know what the answer is, but I can't say it. " A more thorough neurologic assessment was consistent with a Wernicke's type aphasia, showing intact comprehension but difficulty following commands , fluent speech with highly disorganized syntax, and the inability to name objects or repeat phrases. Visual fields were intact without gross visual deficiencies. The remainder …