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The MKSAP Challenge

From the October ACP Observer, copyright 2004 by the American College of Physicians.

Clinical scenario

A 30-year-old man with HIV infection is evaluated because of a one-week history of increasing headaches, low-grade fever, anorexia, nausea and vomiting. He has not received any prescribed medications for the past three years because he believes that herbs and vitamins provide better therapy.

On physical examination, the patient appears lethargic. Temperature is 38.2 C (100.8 F). He has extensive seborrheic dermatitis of the face and appears to have lost weight. His neck is supple. There are no focal neurologic findings. Hematocrit is 32%, the leukocyte count is 2500/L and the platelet count is 150,000/L.

Lumbar puncture is performed. The opening pressure is 39 cm H2O, leukocyte count is 25/L, protein is 65 mg/dL and glucose is 50 mg/dL (simultaneous plasma glucose is 95 mg/dL). An India ink preparation shows many encapsulated budding yeasts, and the cryptococcal antigen titer is greater than 1:8192.

In addition to beginning antifungal therapy, which of the following should be done next?

A. No additional therapy is indicated.
B. Request that a neurosurgeon place a ventriculoperitoneal shunt as quickly as possible.
C. Perform lumbar punctures daily.
D. Give dexamethasone, 8 mg daily for one week.

Answer

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