Case 670 -- A 63 year-old male with confusion and fluent aphasia

Contributed by Sarah Harm, MD and A. William Pasculle, ScD.


The patient is a 63 year-old retired Navy veteran with a history of diabetes mellitus type II who presented to an outside hospital with mental status changes. He suffered clinical deterioration during the first 24 hours of his stay and was referred to our hospital in consideration of possible acute stroke. Presenting symptoms included fluent aphasia, confusion, and speaking gibberish. He also related a recent history of chronic cough, sputum production, and a 15 pound weight loss. As part of his initial stroke evaluation, he underwent CT angiography of the head and neck. This study was remarkable for pulmonary findings consistent with a large apical cavitary lesion (Figure 1). A high resolution chest CT without contrast was then performed, confirming a large cavitary lesion in the right upper lobe with a relatively thin wall (Figure 2). Sputum was collected for Acid Fast Bacilli (AFB) culture. In addition, a lumbar puncture was performed to collect cerebral spinal fluid (CSF) for analysis, AFB culture, and nucleic acid amplification of M. tuberculosis via PCR. Results of both sputum and CSF specimens are listed in the Microbiology and Laboratory sections.


Sputum specimen
Gram stain: Moderate white blood cells present
Many gram positive cocci in chains and pairs
Many "ghost" cells seen suggestive of Acid Fast Bacilli (Figure 3)
AFB stain: Many Acid Fast Bacilli found on smear (Figure 4)
Culture: Acid Fast Bacilli found on culture (8 days after collection)
   Rough, buff colored colonies on LJ slant
   Nitrate positive
   Niacin positive
   DNA probe: Positive for M. Tuberculosis Complex
     Negative for M. Avium Complex

Cerebral Spinal Fluid specimen


Table 1: CSF analysis revealing leukocytosis, predominantly lymphocytosis, low glucose and elevated protein.


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