Psychiatry/Neurology Challenge Cases


Case: Forgetfulness

S: 41 year old male; almost assaulted by a psychopath at a red light; progressive neurological illness over past 6 months; symptoms include forgetfulness, disorganization at work, personality changes, irritability, amnesia, and delusions.

O: (exam) mild dysmetria of all four limbs; wide based ataxic gate; extensor plantar responses; primitive reflexes; (mental status) disorientation; perseverative speech;  rambling sentences, and impairment of word generation, 3-D constructions and clock drawing. (Tests) non-contrast MRI, T1 weighted images generally show no lesions and there is no evidence of calcification or hemorrhage. On T-2, weighted images, the lesions are bright, consistent with prolongation of tissue. There is no evidence of hypointensity. Lesions show marked involvement of the pons bilaterally. Wide spread bilateral hyperintense lesions involving the periventricular white matter, subcortical white matter, gray-white junction, portions of the cerebral cortex and brain stem with bi-frontal, bi-temporal, and bilateral pontine predominance.

The lesions extend into the corpus callosum, but show relative sparing of the basal ganglion and thalamus. The lesions in the left upper frontal lobe show mild hypointensity, but otherwise, the lesions are poorly appreciated on T-1 weighted images. Following contrast administration, the lesions are non-enhancing. CT of chest, abdomen, and pelvis was unremarkable; blood work was unremarkable; lumbar puncture showed no change in the CSF findings including negative cytology and negative flow cytometry; cerebral angiography was negative; right frontal lobe stereotactic biopsy showed gliosis, but no specific findings; EEG showed minimal background slowing.

A: What is your diagnosis?

P: What is your treatment plan?