The Fever That Would Not Wait

A 34-year-old man from rural Guatemala, living in the United States for three years without documented medical care, is brought to the emergency department by his roommate after three days of worsening confusion. His roommate reports that he has had daily fevers, drenching night sweats, and an approximately 10-pound unintentional weight loss over the preceding six weeks. He developed headaches about three weeks ago, initially mild and positional, that have progressively worsened. He has no prior medical history, takes no medications, and denies alcohol or drug use. He works in agricultural labor.

On examination, temperature is 38.9°C, blood pressure 108/68 mmHg, heart rate 114 bpm, and oxygen saturation 97% on room air. He is alert but disoriented to time and place, with marked psychomotor slowing. There is mild nuchal rigidity. Fundoscopy reveals bilateral papilledema. The remainder of the neurologic exam shows no focal deficits. Oral examination reveals white plaques on the buccal mucosa. He appears cachectic with bilateral posterior cervical and axillary lymphadenopathy, each node approximately 1–2 cm, firm and non-tender. No hepatosplenomegaly is appreciated.

A fourth-generation HIV-1/2 antigen-antibody combination test returns positive; HIV-1 RNA viral load is 840,000 copies/mL and CD4 count is 28 cells/μL. Complete blood count shows hemoglobin 9.4 g/dL (normocytic), WBC 3,800 cells/μL with normal differential, and platelets 118,000/μL. Comprehensive metabolic panel is notable for albumin 2.6 g/dL. LDH is elevated at 410 U/L. Chest X-ray shows a small right upper lobe infiltrate with ipsilateral hilar fullness. Serum cryptococcal antigen is negative. MRI of the brain with gadolinium shows leptomeningeal enhancement at the basal cisterns, mild communicating hydrocephalus, and no ring-enhancing lesions. Lumbar puncture is performed with an opening pressure of 32 cm H₂O. CSF analysis: WBC 88 cells/μL (92% lymphocytes), protein 148 mg/dL, glucose 32 mg/dL (serum glucose 96 mg/dL). India ink is negative. CSF cryptococcal antigen is negative. CSF Mycobacterium tuberculosis GeneXpert PCR returns positive with no rifampin resistance detected. AFB smear of CSF is positive.