A 60-Year-Old Woman With Worsening Neuropsychiatric Symptoms

Sridharan Ramaratnam, MD


August 12, 2015

Physical Examination and Workup

The physical examination reveals a well-nourished woman of average build, with a pulse rate of 76 beats/min, blood pressure of 130/78 mm Hg, respiratory rate of 14 breaths/min, and temperature of 98.4° F (36.9° C). She has no thyromegaly, lymphadenopathy, pallor, or jaundice. Cardiac, respiratory, and abdominal examinations are normal. She is incontinent of urine and stool. No signs of meningeal irritation are present.

The patient responds to calls but her attention cannot be sustained. She is disoriented to time and place and is unable to identify her husband or her children. Her memory for recent and past events is impaired. She comprehends simple commands. Her speech is slurred. The cranial nerve examination findings are normal. She has intermittent myoclonic jerks involving all of her limbs. She moves all limbs briskly but is unable to sit or stand without assistance and cannot walk, even with assistance. The patient's reflexes are brisk but symmetric. She responds to pain, but the remainder of her sensory examination cannot be reliably assessed.

The complete blood cell count, fasting and postprandial blood sugars, urea, creatinine, electrolytes, and liver function examinations are all normal, as are serum ammonia, ceruloplasmin, copper, thyroid, and parathyroid hormone levels. Serum levels of antithyroperoxidase antibodies are normal. The enzyme-linked immunosorbent assay (ELISA) for HIV and the Venereal Disease Research Laboratory (VDRL) test are negative. Serum B12, folate levels, and arterial lactate levels are in the normal range. Testing for antinuclear antibodies (ANA), antineutrophil cytoplasmic autoantibodies (ANCA), and antibodies to double-stranded DNA, as well as for antibodies to thyroid peroxidase and thyroglobulin, are all negative. The toxicology screens for lead, mercury, and arsenic are negative. The patient's ECG, echocardiogram, radiographs of the chest, and ultrasonogram of the abdomen are normal. CT scans of the chest and abdomen do not reveal neoplasms or evidence of other illnesses.

MRI of the brain with gadolinium enhancement is normal. Cerebrospinal fluid (CSF) analysis reveals acellular fluid, with normal glucose and protein levels. The CSF bacterial cultures, smears for acid-fast bacilli and Cryptococcus, and cytology are negative. Cryptococcal antigen and measles antibodies are not detected in the CSF. The polymerase chain reaction examinations for mycobacterium tuberculosis and herpes simplex virus are negative.

An electroencephalogram (EEG) is obtained (see Figure).


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