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14th June 2023
A 64-year-old man of no fixed abode presents to the acute medical unit with a 4-week history of intermittent headaches
A 64-year-old man of no fixed abode presents to the acute medical unit with a 4-week history of intermittent headaches, low grade fever, and general malaise. He has no significant past medical history, however, he admits to using intravenous drugs occasionally for recreational purposes. There is a history of weight loss of 7kg over 1 month. On assessment, vital signs are within normal parameters. Pupils are equal and reactive to light bilaterally, however, on assessment of eye movements, he is unable to abduct his left eye. The rest of the neurological examination is normal.
Bloods:
| Hb | 130 g/L | Male (130-180 g/L) |
| White count | 11 x 10^9/L | (4.0-11.0 x 10^9/L) |
| Platelets | 400 x 10^9/L | (150-500 x 10^9/L) |
| Sodium | 146 mmol/L | (135 -145 mmol/L) |
| Potassium | 4 mmol/L | (3.5-5 mmol/L) |
| Urea | 7 mmol/L | (2.5-6.7 mmol/L) |
| Creatinine | 156 μmol/L | (68-150 μmol/L) |
| GFR | 81 ml/min | (>90 ml/min) |
| Calcium | 2.5 mmol/L | (2.05- 2.6 mmol/L) |
| Bilirubin | 10 μmol/L | (3-17 μmol/L) |
| AST | 35 IU/L | (8-40 IU/L) |
| ALP | 13 IU/L | (10-50 IU/L) |
CSF analysis:
| Appearance | Fibrinous | |
| Protein | 1.5 g/L | (<0.45 g/L ) |
| Glucose | 1.8 mmol/L | (2.5-4.4 mmol/L ) |
| White cells | 496 cells/μL (predominantly lymphocytes) | (<5 cells/μL) |
| Gram stain/ culture | No organisms | |
Chest x-ray is normal.
ELISA HIV is negative
Of the options below, which single answer is the most likely diagnosis?
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