Rapid cognitive decline and myoclonus in a 52-year-old woman

Abstract

A 52-year-old woman presented to the emergency department in Las Vegas, NV, with progressively worsening altered mental status for the past 2 weeks. A history of symptoms was obtained from the patient's sister, with whom she was staying. The sister reported that during the week before presentation, the patient had episodes of confusion, intermittent blank staring, blurred vision, bilateral incoordination of the upper and lower extremities, diffi culty following commands, and decreased verbal communication. The patient had also been holding her left hand in a fi st. Two days before presentation, the patient experienced a signifi cant decline in mentation and had multiple episodes of urinary incontinence, which she never had before. During a period of lucidity in the emergency department, the patient denied having fever, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, dysuria, or headache.The patient had a history of major depressive disorder treated with fl uoxetine until 8 days before presentation, when she was switched to escitalopram by an outpatient psychiatrist owing to onset of the psychomotor symptoms. The patient had no prior blood transfusions or surgeries and no known drug allergies.The patient was from California and spoke only Spanish. She was employed by a shoe store, was single, lived alone, and had no children. She had been fully independent in activities of daily living, maintained full-time employment, and was fi nancially stable, but did not have health insurance. She did not smoke, drink alcohol in excess, or use recreational drugs.