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• W2296324741 abstract "CASE Confusion after discharge Mr. G, age 37, is transferred to our medical center from a local hospital for treatment of altered mental status. His wife reports that 1 month ago he had been admitted to a different hospital for a heroin overdose. His urine toxicology screen then was positive for benzodiazepines, cocaine, and opioids. Mr. G's 2-week stay was complicated by respiratory arrest, intubation, and mechanical ventilation. He also developed hypotension, acute renal failure, and aspiration pneumonia, but recovered. His wife says 2 weeks after Mr. G was discharged home, she noticed he was becoming increasingly confused and forgetful. Initially she observed difficulty with short-term memory. He was involved in a motor vehicle accident far from home while reporting to a job he no longer held. She found him confused and watering the lawn in the rain. After she discovered him talking on the phone with no one on the line, she brought him to the emergency room (ER). His urine toxicology screen was negative. Routine examination of cerebrospinal fluid and tests for glucose, protein, lactate, lactate dehydrogenase, red blood cell count, white blood cell count with differential, syphilis serology, Gram's stain, and bacterial culture were negative. Brain MRI showed diffuse new white matter signal abnormality superior to the tentorium of the cerebellum, suggestive of low-grade white matter ischemia or inflammation. Mr. G's mental status did not improve in the ER, and he was transferred to our facility. What is the likely cause of Mr. G's mental status changes? a) white matter disease b) metabolic injury c) infection d) exposure to toxins The authors' observations Based on abnormal brain imaging findings, we initially suspect a type of white matter disorder (Table 1, page 78). (1) We attempt to conduct a thorough history. Table 1 Differential diagnoses: Types of white matter disorders Category Example Genetic Metachromatic leukodystrophy Demyelinative Multiple sclerosis Infectious AIDS dementia complex Inflammatory Systemic lupus erythematosus Toxic Toluene leukoencephalopathy Metabolic Vitamin B12 deficiency Vascular Binswanger's disease * Traumatic Traumatic brain injury Neoplastic Gliomatosis cerebri Hydrocephalic Normal pressure hydrocephalus * Degenerative dementia caused by thinning of subcortical white matter of the brain AIDS: acquired immune deficiency syndrome Source: Reference 1 HISTORY Missing information Attempts to obtain collateral information are largely unsuccessful. Mr. G denies having a history of medical or psychiatric illness. He is vague about substance use but may have a history of opioid and cocaine dependence and alcohol abuse. He says he takes no prescribed or over-the-counter medications and has no known drug allergies. Mr. G's wife provides limited additional information. She married Mr. G 6 months ago; before that, he was in jail for 3.5 years for unclear reasons. He is unemployed, and the couple has no children. Mr. G's wife reports that Mr. G's father had a history of diabetes mellitus and dialysis and died in his 40s from Staph infection of the brain. Mr. G is estranged from his mother. He has no family history of neurologic or psychiatric illness. Mr. G's wife denies that her husband has had recent fever, chills, weight loss, nausea, vomiting, diarrhea, or skin rash. He has no history of alcohol withdrawal symptoms, seizures, headache, diplopia, vertigo, hearing loss, swallowing difficulty, focal weakness, or sensory or speech changes. She did not notice personality or behavior changes in her husband before his recent confusion. The authors' observations During our interview, Mr. G maintains minimal eye contact. His speech is minimal with impaired fluency; he responds to questions with 1- or 2-word answers. …" @default.
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• W2296324741 date "2010-02-01" @default.
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• W2296324741 title "Chasing the Dragon" @default.
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