Cases from the Osler Medical Service at Johns Hopkins University

Presenting features A 26-year-old man with human immunodeficiency virus infection (CD4 count, 3/μL) was admitted for evaluation of a 2-month history of fevers and fatigue and a 1-week history of nausea and abdominal pain. He had no previous history of opportunistic infections. His physical examination was notable for a temperature of 39°C and mild hepatomegaly without significant tenderness. There were no heart murmurs, and he did not have splenomegaly, lymphadenopathy, skin rash, or neurological changes. His white blood cell count was 2.9/μL, his platelet count was 132,000/μL, and his hematocrit was 22.4%. His alkaline phosphatase level was slightly elevated at 152 U/L, but his aminotransferase and bilirubin levels were normal. Evaluation included negative hepatitis serologies, negative blood and mycobacterial cultures, negative toxoplasmosis immunoglobulin (Ig) M and IgG, a nonreactive rapid plasma reagin, a negative purified protein derivative skin test, and negative serum cryptococcal and urine histoplasmosis antigens. A computed tomographic scan of the abdomen (Figure 1) revealed hepatomegaly with a patchy enhancing pattern, periportal edema, and multiple small lesions in the spleen. Figure 1. Computed tomographic scan of the abdomen showing hepatomegaly with a patchy enhancing pattern, periportal edema, and multiple small lesions in the spleen (arrows). Upon further questioning, the patient reported that he had traveled extensively in Italy, France, and Spain while in the military, during which had he consumed unpasteurized milk products. He was currently working as a drill sergeant at a prison. He also had a pet cat and had recent contact with a friend’s kitten. What is the diagnosis?