Make the Dx: Is it the drugs?
Key Takeaways
Can you diagnose this mystery illness?
A 48-year-old woman with alcohol dependence presented with altered mental status lasting a month. Two months previously, she binged on morphine, oxycodone, and heroin for 1 week. Following the binge, she experienced lethargy for about 1 day, and difficulties with arousal for 2 days. She then returned to baseline without symptoms until falling and hitting her head 3 weeks later, from which she developed acute headache.
One day after hitting her head, she began acting strangely. Her actions included sleeping with cremated ashes, brushing her teeth with a comb, showering with her clothes on, and not recognizing family members.
She was finally brought to the hospital and, upon neurological examination, demonstrated that she was only oriented to self. She expressed apraxia, aphasia, and selective mutism, as well as hyperreflexia of the patella, a wide-based gait, and the palmomental reflex, which may be indicative of cerebral pathology.
Tests of the blood, urine, and cerebrospinal fluid (CSF) were all within normal limits. However, results of an EEG showed intermittent, generalized, reactive polymorphic delta slowing indicative of encephalopathy.
Brain MRI without contrast demonstrated white matter signal changes and mild cortical swelling that was also suggestive of diffuse encephalitis.