The differential diagnosis when a TB/HIV patient becomes acutely confused includes the following:
a) acute superimposed infection, e.g. septicaemia, meningitis, malaria;
b) hypoxaemia, e.g. pneumothorax, pneumonia, heart failure, anaemia;
c) metabolic disturbance, e.g. secondary to diarrhoea, hypoadrenalism;
d) adverse drug reaction, e.g. acute confusion may be the first sign of drug-induced acute fulminant liver failure (a useful test, if available, is the prothrombin time).
Always check a blood film for malaria. Do a lumbar puncture if the patient has meningism and it is safe to do a lumbar puncture. Other investigations depend on the laboratory facilities available and clinical clues to the diagnosis.
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