A 35-year-old man with an unremarkable medical history sought treatment for headaches, hearing loss, and night sweats. The headaches were occipital and bilateral and had started 3 months earlier. They came on as the day progressed and were neither positional nor associated with nausea, vomiting, or visual changes. Three weeks before arriving at the hospital, he noted a sense of "fullness" in his ears; he said that spoken voices sounded muffled, and he had difficulty hearing telephone conversations. When someone at the restaurant where he worked dropped a dish, he heard that sound clearly and reported that it was almost painful, causing him to become dizzy. He otherwise denied ear pain or recent trauma. His appetite was good, and he had not lost weight. Although he reported no fever, he did report night sweats for several weeks. He had no rash, diarrhea, abdominal pain, chest pain, shortness of breath, joint complaints, or dysuria. The patient attributed his headaches to stress. He also said that he was exposed to dust at his workplace because of remodeling.
The patient was taking no regular medications and had no drug allergies. He had quit smoking 7 months earlier and drank 10-12 beers per week. He reported no history of intravenous drug use. He lived in New Hampshire, had no pets, and worked as part owner of a restaurant. Exposures included multiple male and female sexual partners with inconsistent condom use, and he had acquired several tattoos 8 months earlier while traveling in Spain and Italy. He had no known tuberculosis exposure. An HIV antibody test had been negative 18 months earlier.
On physical examination, he appeared healthy but anxious. Temperature was 36.7 C, blood pressure 128/84 mm Hg, pulse 80, respirations 16/minute. Sclerae were anicteric, and his pupils reacted to direct and consensual testing and responded normally to accommodation. Funduscopic examination showed no retinal abnormalities. The left tympanic membrane was retracted; both sides demonstrated a small effusion. No vesicles were seen. Bedside testing showed that his hearing was diminished to low volume sounds, but he was able to hear loud sounds, which he found painful. When the examiner clapped his hands loudly a few feet from the patient's ear, the patient exhibited nystagmus. His sinuses were not tender, and the oral mucosa had no lesions. The patient's neck was supple; a 1.5-cm, nontender lymph node was palpated in the left upper anterior cervical chain. No other lymphadenopathy was noted. The remainder of the examination was unremarkable, with negative Romberg test; normal gait; and normal motor, sensory, and reflex performance.
Laboratory evaluation (Table) showed low hematocrit and normal renal and liver function. HIV enzyme-linked immunosorbent assay and confirmatory test were positive. Rapid plasma reagin (RPR) was positive at a titer of 1:128 and was confirmed by a fluorescent treponemal antibody test. Subsequent studies showed a CD4 receptor-positive T-cell (CD4) count of 899/mL and an HIV viral load of 878 copies/mL. A lumbar puncture showed protein 33 mg/dL, glucose 78 mg/dL, 9 erythrocytes/microL, and 8 leukocytes/microL (100% lymphocytes). Cerebrospinal fluid venereal disease research laboratory test (CSF-VDRL) results were negative.