Case 1-2009 — A 57-Year-Old Man with Progressive Cognitive Decline  

Oleh:

Costello, Daniel J. ; Eichler, Florian S. ; Grant, P. Ellen ; Auluck, Pavan K.

Jenis: Article from Journal - ilmiah internasional
Dalam koleksi: The New England Journal of Medicine (keterangan: ada di Proquest) vol. 360 no. 02 (Jan. 2009), page 171-181.

Ketersediaan

Perpustakaan FK Nomor Panggil: N08.K.2009.01 Non-tandon: 1 (dapat dipinjam: 0) Tandon: tidak ada

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Dr. Matthew T. Bianchi (Neurology): A 57-year-old man was transferred to this hospital because of progressive cognitive decline. He had a history of recurrent malignant melanoma of the right conjunctiva and eyelid that was treated at this hospital. Nine days before admission, a nurse from the melanoma clinic who contacted him by telephone for a preappointment interview noted that he was incoherent and unable to answer her questions. Four days later, at a clinic visit, his physician noted that the patient had difficulty understanding the conversation. Options for treatment of the malignant melanoma, including orbital exenteration, were discussed with the patient and his wife. The next morning, at 3 a.m., his wife awoke to find the patient having convulsive movements in bed. The seizure lasted less than 5 minutes, after which he remained unresponsive. Emergency medical services providers were called; on their arrival 10 minutes later, he had regained consciousness but was incontinent of urine, disoriented, and unable to follow commands. He was transported to the emergency department of another hospital. On examination, the patient appeared confused. The vital signs were normal, and the oxygen saturation was 97% while he was breathing ambient air. A lumbar puncture was performed; analysis of the fluid revealed no cells and normal levels of protein and glucose, no organisms were detected on Gram's and acid-fast staining, and polymerase-chain-reaction testing for JC virus was negative. Computed tomography (CT) of the brain revealed generalized atrophy; there was no evidence of hemorrhage. An electroencephalogram showed diffuse theta-range background slowing but no epileptiform activity. He was admitted to the hospital. Fluid-attenuated inversion recovery (FLAIR) and T2-weighted magnetic resonance imaging (MRI) of the brain after the administration of gadolinium showed generalized brain atrophy and diffuse white-matter hyperintensity. Lorazepam, haloperidol, phenytoin, levetiracetam, acyclovir, and ceftriaxone were administered. His mental status deteriorated, and he became intermittently agitated. On the fifth day, he was transferred to this hospital. On further questioning at this hospital, the patient's wife reported that she had noticed occasional episodes of confusion and disorientation during the previous 5 years. During the previous 2 months, she had noticed a change in his behavior, with more frequent episodes of disorientation and progressive impairment in his memory, including forgetting to switch off electrical appliances and having difficulty making out checks and using the computer. A diagnosis of malignant melanoma of the right eyelid had been made approximately 5 years earlier and was treated with excision; recurrent melanomas on the conjunctiva, lower eyelid, and lacrimal caruncle of the right eye were excised during the next 4 years, most recently 2 months before admission. At that time, CT of the head and chest showed no metastatic lesions. The patient had a history of head trauma and extradural hematoma in infancy and had had a left frontoparietal craniotomy, with no apparent residual cognitive deficit. He had emphysema, hypertension, hyperlipidemia, and depression and had undergone bilateral lens implantations. He had hepatitis C virus (HCV) infection (diagnosed more than 15 years earlier) and had a serum HCV RNA level of 1.6 million IU per milliliter 1 month before admission.

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