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Differential Diagnosis for a 45-year-old Woman with HIV Presenting with Neurological Symptoms

  • Single most likely diagnosis
    • Toxoplasmosis: This is the most likely diagnosis given the patient's HIV status and the presence of multiple subcortical lesions in the region of the basal ganglia on the noncontrast head CT. Toxoplasmosis is a common opportunistic infection in HIV patients, particularly those with low CD4 counts, and it characteristically presents with focal neurological deficits and ring-enhancing lesions on imaging.
  • Other Likely diagnoses
    • Primary brain lymphoma: This is another possible diagnosis, as primary brain lymphoma is more common in immunocompromised patients, such as those with HIV. However, it typically presents with a single lesion rather than multiple lesions.
    • Cryptococcal meningitis: While cryptococcal meningitis is a common opportunistic infection in HIV patients, it typically presents with more diffuse symptoms such as headache, fever, and confusion, rather than focal neurological deficits. Imaging may show hydrocephalus or leptomeningeal enhancement rather than discrete lesions.
  • Do Not Miss diagnoses
    • Tuberculosis: Although less common than toxoplasmosis or primary brain lymphoma in HIV patients, tuberculosis (TB) of the central nervous system (CNS) can present with similar symptoms and imaging findings. CNS TB can be deadly if not promptly treated, making it a "do not miss" diagnosis.
    • Progressive multifocal leukoencephalopathy (PML): PML is a rare but potentially fatal opportunistic infection caused by the JC virus, which can affect HIV patients. It presents with progressive neurological decline and characteristic white matter lesions on imaging. While less likely, PML is critical to consider due to its poor prognosis if missed.
  • Rare diagnoses
    • CNS lymphomatoid granulomatosis: This is a rare condition that can occur in immunocompromised patients, including those with HIV. It presents with multiple lesions in the brain and can mimic other conditions such as lymphoma or toxoplasmosis.
    • Cysticercosis: This parasitic infection can cause neurological symptoms and lesions in the brain, particularly in patients from endemic areas. However, it is less common in HIV patients compared to other opportunistic infections.

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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