E M E R G E N C Y   M E D I C I N E

 
HISTORY:
 
Ptosis and anisocoria A 35-year old HIV(+) positive man with a history of homosexual activity and intravenous drug abuse presented to the emergency department after 4 days of increasing headache and one day of nausea and vomiting. He had been noncompliant with all medications and had become increasingly confused prior to presentation.

PHYSICAL:

On physical examination, mild left- sided ptosis and a fixed, dilated left pupil were noted (A). There were no other neurologic deficits. A family member provided a 2 week old photo of the patient in which anisocoria and ptosis were absent.

ANCILLARY TESTS:
 
An emergency noncontrast computed tomographic (CT) scan revealed a large mass that involved deep structures, including the region of the left basal ganglion with extension into the left frontal and temporal lobes surrounded by white matter edema. The left lateral ventricle and third ventricle were markedly compressed and shifted extension into the left frontal and to the right (B). temporal lobes surrounded by The patient was immediately started on intravenous steroids and medications for toxoplasmosis.

HOSPITAL COURSE:
 
Three days after admission, he was free of headache, nausea, and vomiting, and he remained asymptomatic thereafter. A follow-up CT showed multiple ring-enhancing lesions consistent with cerebral toxoplasmosis.

HOSPITAL MEDICINE MARCH 1996:41