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Case 36
A 71 year-old woman is brought to the ER for 36 hours of fever and personality change. She has been
easily distracted and has bumped her left side several times walking through doorways. Her temperature
is 38.1 C. While being examined, she develops rhythmic left face and arm twitching, followed by a
generalized tonic-clonic seizure that stops with lorazepam 2mg IV. After the seizure, she has conjugate
roving eye movements and opens her eyes briefly to sternal rub. Her neck is supple and her pupils are
3mm and briskly reactive. Reflexes are brisk in the left arm and leg, compared with the right, with an
extensor left plantar response. Other than an ACE-inhibitor for hypertension, she takes no
medicationsand is in good health.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?
Case 36
A 71 year-old woman is brought to the ER for 36 hours of fever and personality change. She has been
easily distracted and has bumped her left side several times walking through doorways. Her temperature
is 38.1 C. While being examined, she develops rhythmic left face and arm twitching, followed by a
generalized tonic-clonic seizure that stops with lorazepam 2mg IV. After the seizure, she has conjugate
roving eye movements and opens her eyes briefly to sternal rub. Her neck is supple and her pupils are
3mm and briskly reactive. Reflexes are brisk in the left arm and leg, compared with the right, with an
extensor left plantar response. Other than an ACE-inhibitor for hypertension, she takes no
medicationsand is in good health.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?