A 25-year old man presents in the ER with his wife. The history has to taken from the wife, because the patient is unable to communicate. He was well until 10 o’clock that morning, when he suddenly collapsed and became unconscious. On arrival in the ER, he slowly seems to regain consciousness. In the previous days, he hadn’t complained of anything and was feeling fine. On examination, the patient is semiconscious (GCS 10/15), not wasted, he has no edema and he’s not pale. He has a pulse of 68/min (regular), a blood pressure of 180/120 mm Hg and a respiratory rate of 24/min. He has oral thrush, no Kaposi’s sarcoma and there are no bruits over the carotid arteries. Examination of heart and abdomen show no abnormalities. Neurological examination reveals normal eye movements, the pupils are normal in size and responding to light. The patient can open his mouth and the corneal reflex is intact. He’s also able to hear whispering, but he has asymmetry of the face and his mouth is drooping on the left. Also, both the left arm and leg show absent reflexes and loss of power (0/5) with normal sensation, the right side is normal. He has a normal gag reflex, normal power in the sternocleidomastoid muscles and tongue protrusion is symmetrical. Questions. 1. What’s your diagnosis? 2. What investigations should be done?
Answers. 1. This young man who was previously healthy presented with a stroke and, as was suggested by the oral thrush, is very likely to be HIV-positive. Ischemic strokes are commonly seen in HIV-infected individuals. The mechanism is not yet understood; it has been hypothesized that the drugs used in HAART affect lipid and glucose levels, which are biomarkers associated with ischemic stroke risk. However, other studies showed that exposure to antiretroviral treatment did not significantly influence the mechanisms of stroke. A stroke in the cortex supplied with blood by the MCA could indeed present with impaired speaking. However, in this case it’s not sure whether his speaking his impaired because he’s not fully conscious. 2. Since an infarction and a brain bleed present in the same way, a CT-scan needs to be done as soon as possible; this is crucial, because you’d be killing your patient by administering tPA when he turns out to be hemorrhaging. Later on, an HIV-test is indicated because of the oral thrush. However, the information you have so far is still rather scanty, while one would be particularly interested in any complaints relating to the nervous system (any similar complaints in the history) and cardiovascular system (hypertension, history of heart disease, palpitations etc.). It may be possible to take a more detailed history in the next 24 – 48 hours as the patient recovers. Also, in addition to the standard examination a full neurological examination should be done. Lastly, careful examination of the carotids and the heart is important as thrombi may arise from potential abnormalities and embolize to the brain. Literature: ‘The Clinical Book’ (EE Zijlstra, College of Medicine, Blantyre Malawi), page 84 – 89.
