A 41-year-old African American man presented with the chief complaint of a constant, dull headache for 3 days. The headache had a gradual onset and was associated with nausea and mild neck stiffness that was not relieved by acetaminophen. The man denied experiencing visual disturbances, fever, night sweats, weight loss, cough, shortness of breath, emesis, or weakness. He had no recent history of trauma or sick contacts.
His medical history was significant for a previously treated unknown sexually transmitted disease (STD). He had no known drug allergies. He denied use of tobacco, excessive alcohol, and illicit drugs; he had never been incarcerated or homeless; and to the best of his knowledge, he had not been exposed to tuberculosis (TB). He had no pets, had lived in New Orleans all his life, and had not traveled outside of Louisiana.
On physical examination, the patient's temperature was 37.5°C (99.5°F), his pulse rate was 77 beats per minute, his respiration rate was 18 breaths per minute, and his blood pressure was 130/77 mm Hg. He was alert, oriented, and in no apparent distress. His pupils were equal and reactive to light and accommodation, and extraocular movements were intact.
The funduscopic examination revealed mild blurring of disc margins and absence of venous pulsations. The patient had decreased flexion and extension of the neck. His cranial nerves were intact, and no gross motor or sensory deficits were noted.
Laboratory tests yielded the following results: white blood cell count, 4100/μL, with 73% polymorphonuclear leukocytes, 4% bands, 12% lymphocytes, and 10% monocytes; hemoglobin level, platelet count, and electrolyte levels, within normal limits; aspartate aminotransferase level, 113 U/L; and alanine aminotransferease level, 138 U/L.
ACT scan of the head revealed a cerebellar vermian mass of 1.8 cm with associated vasogenic edema and moderate cerebral atrophy (Figure 1). An MRI scan of the brain revealed 2 predominant ring-enhancing lesions with surrounding vasogenic edema (Figure 2).
