Case 20-2017: A 48-Year-Old

Man with Weight Loss,

Confusion, Skin Lesions and
Pancytopenia
HISTORY
Chief Complaint:
A 40 year-old man seen in ED for confusion.
HPI:
Hx taken by family:
-Confusion started 4 days earlier while vacationing in Mexico, also
euphoric and easily distracted
-associated with agitation 1 day ago
-reported having been in usual health before trip
-1 year hx of unexplained weight loss
Past Medical History
• Hx of multiple non-melanoma skin cancer treated with cryotherapy
• Sigmoidoscopy 12 years earlier, removal of foreign body from colon
• NKDA
• No report of other hospitalizations, illnesses, or surgeries
Family History
• No family history of dementia, stroke, seizure disorder, cancer,
depression, bipolar disorder or schizophrenia
Social History
• Occupation: lawyer; single, lives alone
• Intermittent condom use, history of sexual encounters with men
• Drank alcohol in moderation
• Non-smoker
• Does not use illicit drugs
• Recently on a diet with low in-take of sugar
ON EXAMINATION
General Assessment:
Appears thin and agitated
Displayed anosognosia and confabulation
Had nonfluent aphasia and perseverated when speaking
Vital Signs:
• Temperature: 35.8 degrees C
• Pulse: 71 beats/min
• BP: 120/62 mm Hg
• RR: 16 breaths/min
• SaO2: 99% OA
General Assessment:
Appears thin and agitated
Displayed anosognosia and confabulation
Had nonfluent aphasia 6 hour after presentation, lasting 2 minutes
Perseverated when speaking
Physical Examination
CNS:
Alert and oriented to city and year, not month
Not oriented to place (emergency department in hospital)

Cranial Nerves: II-XII showed left-eye ptosis, intermittent twitching on

right side of face;

Pronator drift + on R side of body; Gait slow, cannot walk in tandem,

cannot walk on toes or heels

Motor, sensation, DTRs, normal; Babinski and cerebellar signs ne

Physical Examination (continued)
Skin:
Medial left knee: purple-brown scaly papule (0.5 cm)
Medial left palmer foot: non-blanching purple-brown patch (1.5 cm)
Left arm: erthyematous scar
Chest: red plaque with heaped up central scale (3 cm), hemorrhagic
crust, and purulent d/c
Left flank: red plaque with focal areas of scale and brown crust (4 cm)
Back: large, scaly red plaque
Face: gritty papules
Scalp: flaky scale
Hard and soft palates: purple macules
INVESTIGATIONS
Labs:
Hct: 27.7% Na+: 132
Hgb: 9.7 g/dl K+: 3.2
White-cell count: 3130 per Cl-: 98
mm3 CO2: 23
Diff: Neut.: 60 Glucose: 121
Lymph. 28.4 Protein
Mono. 8.3 total: 9.1 g/dl
Eosino. 1.6 albumin: 3.7 g/dl
Baso. 0.3 globulin: 5.4 g/dl
Platelets: 132 000 Lipase: 136 U/L
Labs (continued)
Red-cell indexes, anion gap, renal-function tests ALL NORMAL
Levels of calcium, phosphorus, magnesium, AST, ALT, ALP, total
bilirubin, direct bilirubin, vitamin B12, and thyrotropin ALL NORMAL

Urinalysis
+1 leukocyte esterase; +1 bacteria; pH 6.0; specific gravity 1.014; 3-5
RBC and 10-20 WBCs per high power field
Urine and blood toxicology screens negative
Imaging
CT Head
-showed ill-defined hypodensities in white matter of frontal lobe,
extending into genu of corpus callosum and posterior periventricular
white matter
-extraaxial calcification (4 cm) overlying right frontal lobe (query:
partially calcified meningioma)
Imaging (continued)
MRI head and neck w/ and w/out contrast
-abnormal hyperintense signal in frontoparietal white matter (more
prominent in right than in left frontal lobe, extending into genu of
corpus callosum); no local mass effect or abnormal restricted diffusion
-small exophytic hypointense lesion along right frontal lobe suggesting
meningioma; mild bilateral prominence of parotid glands having
restrited diffusion
Lumbar puncture
-opening pressure: 9 cm of water, CSF was clear and colorless; no
xanthocrhomia;
CSF showed 4 red cells and 7 white cells per microliter, white-cell
differential count of 80% lymphocytes, 20% monocytes; protein level
97 mg/dl; glucose 53 mg/dl
Gram stain of CSF showed mononuclear cells, very rare
polymorphonuclear lymphocytes, and no organisms
Differential Diagnoses
Primary Psychiatric Disorders
+ mania, agitation, disinhibition, apathy to self-appearance

However, neuro exam showed no evidence of mania; no visual or

auditory hallucinations, no tangential thinking and he engaged with
examiner in a logical manner

Unlikely to be a psychiatric cause

Differential Diagnoses (continued)
Metabolic and Toxic Disorders
+ tremor, diet of low added sugar (Wernicke’s Encephalopathy),
+ dementia and psychosis due to Vitamin B deficiency
+ HIV infection associated with Fulminant Encephalopathy (FE)

No global confusion, nystagmus or cerebellar dysfunction to support

Wernicke’s Encephalopathy,
Vit. B deficiency usually accompanied by visual, sensory and motor
impairment
Negative toxicology screening makes FE unlikely
Differential Diagnoses (continued)
Cancers of the CNS
+ HIV infection, age (4th decade of life) may suggest CNS lymphoma or high-
grade glioma
+ cutaneous lesions support Kaposi’s sarcoma with brain mets

No neurological deficits in patient (weakness or sensory dysfunction) that

would support these cancers
Imaging does not favor cancer differentials: lack of CT head findings (T2-
weighed with contrast showing hyperintensities, diffusion restriction and
mass effects)