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A 50-year-old man with acquired immunodeficiency syndrome (AIDS) presents to the hospital with severaldays of confusion, followed by a decline in level of consciousness. A computed tomography scan of thebrain demonstrates diffuse atrophy, but no acute findings. A lumbar puncture is performed, and openingpressure is 60 cm (normal is <20 cm). The spinal fluid further demonstrates a glucose of 10 mg/dL (normal is4580 mg/dL), protein of 140 mg/dL (normal is 1545 mg/dL), normal red blood cells, and 9 whiteblood cells/mL (normal is <5 cells/mL) with a lymphocytic predominance. Based on your suspecteddiagnosis and while awaiting further studies, which of the following is the best course of action afterremoving a large volume of cerebrospinal fluid (CSF)?
Explanation
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With an underlying diagnosis of AIDS, the patient is at risk for multiple opportunistic infections. The constellation of significantly elevated intracranial pressure with CSF lymphocytosis, low glucose, and high protein is classic for cryptococcal meningitis. Treatment with amphotericin B and flucytosine should be initiated, as well as daily lumbar punctures to reduce intracranial pressure. Although lumbar drain may be used in place of daily lumbar punctures, and chronic obstructive hydrocephalus may be treated with a ventriculoperitoneal (VP) shunt, during the acute course of the infection a VP shunt should be avoided due to risk of fungal seeding into the abdomen.
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Reference
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Bradleys NiCP, 7th edn, Chs. 77, pp. 11021120 and 79, pp. 11471158
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Option 1
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Is Correct (Option 1):
Emergent ventriculoperitoneal shunt
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Option 2
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Is Correct (Option 2):
Initiate amphotericin B and flucytosine
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Option 3
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Is Correct (Option 3):
Initiate antituberculous therapy
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Option 4
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Is Correct (Option 4):
Initiate acetazolamide
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