A 48-year-old man presented with 4 days of confusion, 1 year of unexplained weight loss, and skin lesions. Imaging showed ill-defined white matter abnormalities and a possible meningioma. Labs found pancytopenia. Differential diagnoses included primary psychiatric disorders, metabolic/toxic disorders, and cancers, but findings did not fully support these.
A 48-year-old man presented with 4 days of confusion, 1 year of unexplained weight loss, and skin lesions. Imaging showed ill-defined white matter abnormalities and a possible meningioma. Labs found pancytopenia. Differential diagnoses included primary psychiatric disorders, metabolic/toxic disorders, and cancers, but findings did not fully support these.
A 48-year-old man presented with 4 days of confusion, 1 year of unexplained weight loss, and skin lesions. Imaging showed ill-defined white matter abnormalities and a possible meningioma. Labs found pancytopenia. Differential diagnoses included primary psychiatric disorders, metabolic/toxic disorders, and cancers, but findings did not fully support these.
A 48-year-old man presented with 4 days of confusion, 1 year of unexplained weight loss, and skin lesions. Imaging showed ill-defined white matter abnormalities and a possible meningioma. Labs found pancytopenia. Differential diagnoses included primary psychiatric disorders, metabolic/toxic disorders, and cancers, but findings did not fully support these.
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Case 20-2017: A 48-Year-Old
Man with Weight Loss,
Confusion, Skin Lesions and Pancytopenia HISTORY Chief Complaint: A 40 year-old man seen in ED for confusion. HPI: Hx taken by family: -Confusion started 4 days earlier while vacationing in Mexico, also euphoric and easily distracted -associated with agitation 1 day ago -reported having been in usual health before trip -1 year hx of unexplained weight loss Past Medical History • Hx of multiple non-melanoma skin cancer treated with cryotherapy • Sigmoidoscopy 12 years earlier, removal of foreign body from colon • NKDA • No report of other hospitalizations, illnesses, or surgeries Family History • No family history of dementia, stroke, seizure disorder, cancer, depression, bipolar disorder or schizophrenia Social History • Occupation: lawyer; single, lives alone • Intermittent condom use, history of sexual encounters with men • Drank alcohol in moderation • Non-smoker • Does not use illicit drugs • Recently on a diet with low in-take of sugar ON EXAMINATION General Assessment: Appears thin and agitated Displayed anosognosia and confabulation Had nonfluent aphasia and perseverated when speaking Vital Signs: • Temperature: 35.8 degrees C • Pulse: 71 beats/min • BP: 120/62 mm Hg • RR: 16 breaths/min • SaO2: 99% OA General Assessment: Appears thin and agitated Displayed anosognosia and confabulation Had nonfluent aphasia 6 hour after presentation, lasting 2 minutes Perseverated when speaking Physical Examination CNS: Alert and oriented to city and year, not month Not oriented to place (emergency department in hospital)
Cranial Nerves: II-XII showed left-eye ptosis, intermittent twitching on
right side of face;
Pronator drift + on R side of body; Gait slow, cannot walk in tandem,
cannot walk on toes or heels
Motor, sensation, DTRs, normal; Babinski and cerebellar signs ne
Physical Examination (continued) Skin: Medial left knee: purple-brown scaly papule (0.5 cm) Medial left palmer foot: non-blanching purple-brown patch (1.5 cm) Left arm: erthyematous scar Chest: red plaque with heaped up central scale (3 cm), hemorrhagic crust, and purulent d/c Left flank: red plaque with focal areas of scale and brown crust (4 cm) Back: large, scaly red plaque Face: gritty papules Scalp: flaky scale Hard and soft palates: purple macules INVESTIGATIONS Labs: Hct: 27.7% Na+: 132 Hgb: 9.7 g/dl K+: 3.2 White-cell count: 3130 per Cl-: 98 mm3 CO2: 23 Diff: Neut.: 60 Glucose: 121 Lymph. 28.4 Protein Mono. 8.3 total: 9.1 g/dl Eosino. 1.6 albumin: 3.7 g/dl Baso. 0.3 globulin: 5.4 g/dl Platelets: 132 000 Lipase: 136 U/L Labs (continued) Red-cell indexes, anion gap, renal-function tests ALL NORMAL Levels of calcium, phosphorus, magnesium, AST, ALT, ALP, total bilirubin, direct bilirubin, vitamin B12, and thyrotropin ALL NORMAL
Urinalysis +1 leukocyte esterase; +1 bacteria; pH 6.0; specific gravity 1.014; 3-5 RBC and 10-20 WBCs per high power field Urine and blood toxicology screens negative Imaging CT Head -showed ill-defined hypodensities in white matter of frontal lobe, extending into genu of corpus callosum and posterior periventricular white matter -extraaxial calcification (4 cm) overlying right frontal lobe (query: partially calcified meningioma) Imaging (continued) MRI head and neck w/ and w/out contrast -abnormal hyperintense signal in frontoparietal white matter (more prominent in right than in left frontal lobe, extending into genu of corpus callosum); no local mass effect or abnormal restricted diffusion -small exophytic hypointense lesion along right frontal lobe suggesting meningioma; mild bilateral prominence of parotid glands having restrited diffusion Lumbar puncture -opening pressure: 9 cm of water, CSF was clear and colorless; no xanthocrhomia; CSF showed 4 red cells and 7 white cells per microliter, white-cell differential count of 80% lymphocytes, 20% monocytes; protein level 97 mg/dl; glucose 53 mg/dl Gram stain of CSF showed mononuclear cells, very rare polymorphonuclear lymphocytes, and no organisms Differential Diagnoses Primary Psychiatric Disorders + mania, agitation, disinhibition, apathy to self-appearance
However, neuro exam showed no evidence of mania; no visual or
auditory hallucinations, no tangential thinking and he engaged with examiner in a logical manner
Unlikely to be a psychiatric cause
Differential Diagnoses (continued) Metabolic and Toxic Disorders + tremor, diet of low added sugar (Wernicke’s Encephalopathy), + dementia and psychosis due to Vitamin B deficiency + HIV infection associated with Fulminant Encephalopathy (FE)
No global confusion, nystagmus or cerebellar dysfunction to support
Wernicke’s Encephalopathy, Vit. B deficiency usually accompanied by visual, sensory and motor impairment Negative toxicology screening makes FE unlikely Differential Diagnoses (continued) Cancers of the CNS + HIV infection, age (4th decade of life) may suggest CNS lymphoma or high- grade glioma + cutaneous lesions support Kaposi’s sarcoma with brain mets
No neurological deficits in patient (weakness or sensory dysfunction) that
would support these cancers Imaging does not favor cancer differentials: lack of CT head findings (T2- weighed with contrast showing hyperintensities, diffusion restriction and mass effects)
[FREE PDF sample] (Ebook) Netter’s Correlative Imaging: Neuroanatomy: with NetterReference.com Access, 1e by Thomas C. Lee MD, Srinivasan Mukundan Jr. MD PhD ISBN 9781437704150, 1437704158, 2014001295 ebooks
[FREE PDF sample] (Ebook) Netter’s Correlative Imaging: Neuroanatomy: with NetterReference.com Access, 1e by Thomas C. Lee MD, Srinivasan Mukundan Jr. MD PhD ISBN 9781437704150, 1437704158, 2014001295 ebooks
