Cases That Test Your Skills

A mysterious physical and mental decline

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Since Mr. C developed intermittent fever, hematuria, and fatigue 2 months ago, his short-term memory has diminished so much that he forgets to eat. What’s going on?



HISTORY: ‘Not himself’

Mr. C, age 69, presents to the emergency department complaining of intermittent fever of about 100°F, hematuria, headache, weakness, fatigue, and decreased appetite over 2 months. Testing shows acute renal failure, elevated C-reactive protein, and increased sedimentation rate. The attending internist admits Mr. C with a working diagnosis of temporal arteritis and acute renal failure, administers corticosteroids for headache, and orders a right temporal artery biopsy, which shows no signs of vasculitis.

Family members report that Mr. C has not been himself—he has become increasingly withdrawn and “emotionless.” Mr. C’s wife says her husband has needed help with dressing and eating because of short-term memory loss over 9 months. She says he has lost 20 to 30 lb.

The patient’s cognitive function appears to have worsened since he developed these physical symptoms. Mrs. C also reports that he has had weakness and fatigue for 8 months.

One month earlier, the patient was admitted to a different hospital and treated for 2 weeks with IV antibiotics for fever of unknown origin. Results of lumbar puncture and extensive rheumatologic, infectious disease, urologic, and gastroenterologic evaluations were normal.

The internal medicine physician requests a psychiatric consultation. During our interview, Mr. C is cooperative, shows no signs of acute distress, is well groomed and dressed appropriately, and maintains eye contact. Speech rate and volume are low, with normal articulation and coherence, diminished spontaneity, and paucity of language. Mrs. C tells us her husband was lively and talkative before his recent illness. His mood is euthymic, and he is pleasant and cheerful during the evaluation.

The authors’ observations

Initially, we suspect an underlying medical condition is causing Mr. C’s psychiatric symptoms.

Mr. C’s wife reports that her husband stopped drinking 2 years ago after his family expressed concern about his health. Mr. C’s past alcohol use could not be quantified. He has not abused illicit drugs and has no personal or family history of dementia, trauma, or psychiatric or neurologic disorders.

EVALUATION: Impaired memory

Mr. C is afebrile during the initial physical examination, but fever returns within several days. Neurologic examination is normal, and negative rapid plasma reagin rules out syphilis. Vitamin B12 and folate levels are normal, as is thyroid function. Other laboratory findings are outside normal limits (Table).

Urine is cloudy with 2+ protein, 3+ blood, and trace leukocyte esterase. The presence of protein and blood suggests a glomerular disease such as a glomerulonephritis.

A positive leukocyte esterase test results from the presence of white blood cells, either as whole cells or as lysed cells. An abnormal number of leukocytes may appear with upper or lower urinary tract infection or in acute glomerulonephritis.

Chest radiography shows increased bilateral pulmonary vasculature, which can indicate pulmonary hypertension.

Mr. C shows variable and incongruent affect and mood, often shifting from labile to blunted. He denies depressed mood. At times he is disinhibited and makes inappropriate remarks. His thought processes are decreased but generally logical and goal-directed. Mr. C reports no hallucinations or suicidal thinking. He has concrete reasoning with regard to his medical condition and linear associations with fair to poor insight/judgment. He exhibits intact impulse control and is oriented to person, place, and time.

Mr. C has fair attention and concentration but impaired recent memory. He cannot recall yesterday’s events without help.

Mr. C’s Mini-Mental State Examination score of 21/30 suggests markedly impaired executive functioning and cognitive deficits. The attending psychiatrist recommends brain MRI.


Mr. C’s laboratory findings

ValueNormal range
WBC15.14.8 to 10.8 cells/μL
Hb913.8 to 17.5 g/dL
Hct25.9%40% to 54%
MCV89.780 to 94 fL
BUN1197 to 18 mg/dL
Cr12.10.7 to 1.3 mg/dL
Na125136 to 145 mmol/L
K6.53.5 to 5 mEq/dL
HCO313.522 to 29 mmol/L
ECR12530 mm/hr
WBC: white blood cell; Hb: hemoglobin; Hct: hematocrit; MCV: mean corpuscular volume; BUN: blood urea nitrogen; Cr: creatinine; Na: sodium; K: potassium; HCO3: bicarbonate; ESR: erythrocyte sedimentation rate

The authors’ observations

Mr. C shows markedly impaired cognitive function without significant impairment of attention and concentration despite his progressive deterioration and increasing disability. Urine toxicology shows no illicit substances. Given his lack of a previous mood disorder and his family’s description of him as formerly vibrant and cheerful, he likely does not have a mood disorder.

Based on the history of events, including the symptom pattern, we rule out delirium. We suspect that Mr. C has dementia secondary to a general medical condition. His symptoms seem to be directly related to his medical complaints and do not have a waxing and waning course. The internal medicine physician orders additional laboratory tests.

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