Case presentation A 35-year-old female presented to the emergency department with a several-day history of right-sided abdominal pain and severe headaches.  Initial examination Afebrile Tachycardic with notable rigors Right upper quadrant tenderness No weight loss, night sweats, respiratory symptoms, or cardiac symptoms observed Neurological examination – No focal deficits CT scan of the abdomen and pelvis Extensive periportal, upper abdominal, and periaortic lymphadenopathy 2.8 cm left adnexal cyst, suggesting possible metastatic disease Brain MRI Performed for staging Punctate, faint enhancement in the right medial occipital lobe (thought to be vascular) Intracranial metastasis disease – No evidence Laboratory findings Reactive HIV antibodies  – Positive CD4 count – 145 cells/uL Viral load – 158,000 copies/mL Syphilis total IgG and IgM – Positive Rapid plasma reagin test – Negative…