A 35-year-old man with changed mental status and multiple intracerebral lesions

Article Abstract:

A 35-year-old man developed difficulty remembering and carrying out activities dependent on previously acquired information, as well as remembering new information. He felt lightheaded, and had trouble walking, with a tendency to fall to the left side. Chronic low-back pain worsened, and muscle pain in the left shoulder and chest was diagnosed as muscle strain. His physical examination was essentially normal, except that his reflexes were stronger than normal. Magnetic resonance imaging (MRI) scans of the skull showed extensive edema (build-up of fluid) and injury. Laboratory tests were not enlightening, including brain biopsy, lumbar puncture (removal of fluid from the spine) and removal of the left testis (orchidectomy), which indicated past inflammation (orchitis). After one week of hospitalization he was less alert and weaker. Treatment with steroids improved the patient's condition. The tests and their results are described in detail. Several diagnoses were considered, included metastatic cancer to the brain. A diagnostic report was received on the 16th day of hospitalization, indicating that the patient was suffering from tertiary central nervous system syphilis (neurosyphilis). The one test that was not performed was a blood test for syphilis. The development and progression of the disease is described. Neurosyphilis is now rare except among patients with immune system disorders, and the diagnosis is easily missed. It was suggested that routine blood tests might be resumed so that these unusual cases would be diagnosed. Brain biopsy and orchidectomy are not diagnostic procedures for neurosyphilis, and it is unfortunate that the diagnosis did not proceed along other lines. (Consumer Summary produced by Reliance Medical Information, Inc.)

Diagnosis, Syphilis, Central nervous system diseases, Neurosyphilis

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A 60-year-old man with multiple cerebral infarcts and cutaneous hemorrhagic lesions

Article Abstract:

A 60-year-old obese man was well until persistent pain developed in both sides of his face and head. After eight days of severe headache he was admitted to a hospital, where initial laboratory tests were normal. Weakness in the left arm and other neurological symptoms developed. Fever was also noted. On the fifth day, abnormal findings were noted on CT scan of the brain. By the seventh hospital day, the left side of his body was paralyzed, and he was confused and agitated. He was found to have elevated lactic dehydrogenase (LDH, an enzyme that indicates tissue damage). Upon transfer to Massachusetts General Hospital, the patient was able to give his name, but was generally disoriented. His condition deteriorated, and he died on the 11th day after admission. Among the diseases considered in arriving at a final diagnosis were herpes simplex encephalitis and other brain infections, thrombocytopenia (abnormal decrease in the number of blood platelets, causing hemorrhage), fungal infections, some types of vasculitis, and blood coagulation disorders such as thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. Postmortem examination revealed cancer of the right lung, disseminated intravascular coagulation, and nonbacterial thrombotic endocarditis (inflammation of the heart lining), with clots spreading to the heart, spleen, kidneys, pancreas, and colon. Clots blocked circulation in both sides of the brain, caused brain hemorrhages. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Lung cancer, Adenocarcinoma, Diagnosis, Differential, Differential diagnosis, Endocarditis

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A 45-year-old man with confusion, seizures, and few focal findings

Article Abstract:

A 45-year-old man was diagnosed with melanoma that had metastasized to his brain. The patient was admitted to the hospital with increasing confusion and increased levels of white blood cells. He had begun experiencing a metallic taste in his mouth and a decreased appetite three-and-a-half months earlier. A rash had appeared on the right side of his torso three months earlier, but it had disappeared after a week. He had begun experiencing slurred speech and confusion one month before admission. His confusion had increased, and he had begun having difficulty remembering things and walking. He had had a melanoma removed from his back 12 years earlier. A computed tomographic (CT) scan and a magnetic resonance imaging (MRI) scan of his cranium showed abnormalities in portions of his brain. A biopsy of brain tissue revealed that the melanoma had spread to his central nervous system. The patient was transferred to a hospice, and he died three weeks later.

Melanoma, Nervous system diseases

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