The patient is a 79 year old man who had been living in the southwest for many years. In January he was unable to write a check because his hands were shaking. He thought this was due to drinking over the holidays but when he became confused he was brought to the physician by his son.

History elicited from the son is of a 2 week duration of tremor, progressive confusion, gait and speech disturbance and 15 lb weight loss in a chronic alcoholic who had been on a binge over the holidays. Past history was significant for 40 PY of tobacco.

1. What is your differential diagnosis?

The patient was treated with vitamins but over the next few weeks became profoundly disoriented and complained of difficulty swallowing. He was admitted to the local hospital after a CT scan of the chest showed multiple small nodules in the right lung. BAL cultures and cytology were negative. The patient had fever to 106F and was treated with ceftriaxone, imipenem, and azithromycin.

A lumbar puncture was performed:

500 RBC, 90 WBC, glucose 27, protein 205, 67% lymphocytes

Cytology of CSF showed inflammation with neutrophils/lymphocytes. Cultures (fungal, crypto, AFB) pending; serum VDRL, RPR, TSH, toxo, HIV, c-ANCA, ANA, negative; protein electrophoresis negative; B12, folate, serum IgM normal; ESR 56.

2. What is your assessment of the lung nodules, mental status changes and fever now?