A 73-year-old man with a history of hypertension and chronic kidney disease presents with a left facial droop and left leg weakness. The facial droop and leg weakness developed 3 weeks ago, while he was vacationing in upstate New York. His symptoms have not progressed since initial onset. He reports no rash, headache, joint pain, visual changes, fevers, night sweats, or weight loss. His cancer screening is up to date and unremarkable. He is a former smoker with a 12 pack-year history, having quit 40 years ago. He is afebrile, and other vital signs are normal. On physical examination he has a left lower facial droop with sparing of the forehead muscles. Lower extremity strength is preserved and reflexes are normal; however, he has a subtle gait abnormality characterized by slight dragging of his left leg with ambulation. His white blood cell count is normal. Tests for toxoplasma, Lyme disease, cryptococcal antigen, and human immunodeficiency virus are negative. T1-weighted magnetic resonance imaging (MRI) of his brain demonstrates multiloculated ring-enhancing fluid collections involving the right basal ganglia, insula, and frontal lobe (Figure). Computed tomography imaging of the chest, abdomen, and pelvis is unremarkable.
Posted on: Mon, 08 Dec 2014 16:50:28 +0000
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