Clinical reasoning: A 35-year-old man with a right hemiplegia and a cerebral mass

Abstract

A 35-year-old man presented with progressive right face, arm, and leg weakness, and diffuse headache. He lived in rural northwest Argentina. He had a past medical history of sexually transmitted diseases. On examination, he was alert and fully oriented, and had a right hemiparesis with hyperreflexia and an extensor plantar reflex. Apart from low grade fever, the rest of the physical examination was unremarkable. The complete blood count revealed leukopenia (3,300 leukocytes/mL); renal function, liver tests, electrolytes, erythrocyte sedimentation rate, and glucose level were normal. He tested positive for HIV with a CD4 count of 18 cells/mm3 and viral load of 133,400 copies/mm3. Brain CT showed a nonenhancing left temporoparietal lesion with surrounding edema and midline shift.