CASE SCENARIO

CASE 1.
A 62-year old man was taken to a local hospital by his family
because he seemed agitated. He vomited once and was
complaining of a smell of rotten eggs. In the emergency room
he had a generalized tonic-clonic seizure. Twenty days before
he had experienced some flu-like symptoms and dry cough
which lasted several days and was complaining of pain at both
temples. During examination he was confused, uncooperative,
and mildly febrile. He perseverated in saluting when asked to
say goodbye. His speech was paraphasic and he could not
understand complex commands. Right toe was extensor.

 SUMMARY: A 62-year-old man presenting with

acute confusional state and focal neurological
findings consisting of aphasia and right
Babinskis sign. Also described are a
generalized tonic-clonic seizure and olfactory
hallucination (smell of rotten eggs).

DIFFERENTIAL DIAGNOSIS:

1. Viral encephalitis ( HSV,EBV, CMV, VZV);

2. Brain abscess;
3. Tuberculous meningitis;
4. Toxoplasmosis;
5. Brain tumors;
6. Subdural hematoma.

CASE 2.
A 33-year-old woman was brought to ER by her sister because of
headache, generalized weakness, and decreased level of
consciousness. One day prior to this event, after lifting a heavy box
of books, the patient developed severe left temple and orbital pain
that quickly radiated to her neck. She vomited several times before
finding her way to bed, where she thought she might have lost
consciousness momentarily. Her sister discovered her sleepy and
difficult to arouse. Two weeks earlier, while visiting her parents, she
experienced sudden sharp headache and nausea. She visited a local
hospital and was diagnosed with tension headache. The headache
persisted for 3 days during time she remained in bed too sick to do
her usual activities. In the ER she was lethargic. Bilateral retinal
hemorrhages were noted around the optic discs (subhyaloid). She
was able to move her upper extremities and withdraw her lower
extremities to pain. Babinskis signs could be elicited on both sides.

 SUMMARY: A 33-year-old woman with chief

complaints of severe headache and decreased LOC. 2
previous episodes of severe headache and vomiting
(one with neck pain) and loss of consciousness after
strenuous exercise were reported 1 day and 2 weeks
prior to admission. The neurological examination
shows a lethargic patient with retinal hemorrhages,
lower extremities weakness, and bilateral Babinskis
signs. In conclusion: Sudden onset of headache,
mental status changes, and focal findings.

DIFFERENTIAL DIAGNOSIS:
1. Acute vascular event (SAH);
2. Space-occupying lesions;
3. Infectious/inflammatory processes (meningitis,
meningoencephalitis, vasculitis).

CASE 3.
A 21-year-old woman started complaining of double vision,
speech difficulty, and dysphagia. For the last month she had
tended to slur her speech, dribble saliva while talking, and
occasionally choke on food. She had been aware of double
vision while watching television in the evening. Her husband
had noticed that her left eyelid at times seemed droopy,
especially under sunlight. On examination there was bilateral
ptosis, worse on the left, and bilateral horizontal gaze
limitation. On the right, adduction was complete, but
abduction was decreased. There was upward gaze limitation
and bilateral facial weakness with diminished gag reflex.
Motor strength in the limbs, as well as DTR and sensation
were normal.

 SUMMARY: A 21-year-old woman with history

of diplopia, dysarthria, and dysphagia, and
neurological findings of ptosis,
ophthalmoparesis, facial weakness, and
diminished gag reflex.

DIFFERENTIAL DIAGNOSIS:

1. Brainstem patology;
2. Myasthenia gravis;
3. Botulism;
4. Myopathy;
5. Motor neuron disorder.

Multiple choice questions:

1. A pure sensory stroke is most likely with damage
to the:
(A) internal capsule
(B) thalamus
(C) hippocampus
(D) globus pallidus
(E) pons
The answer is B.

 2. The most common manifestation of muscle

weakness with myasthenia gravis is:
(A) diaphragmatic weakness
(B) wristdrop
(C) footdrop
(D) ocular muscle weakness
(E) dysphagia
The answer is D.

 3. Localization of an encephalitis to the medial

temporal or orbital frontal regions of the brain is
most consistent with:
(A) Treponema pallidum
(B) varicella zoster
(C) herpes simplex
(D) Cryptococcus neoformans
(E) Toxoplasma gondii
The answer is C.

 4. Recurrent meningitis often develops in persons

with:
(A) otitis media
(B) epilepsy
(C) multiple sclerosis
(D) Wipples disease
(E) CSF leaks
The answer is E.