History
Mr. Yuen was a 70-year old gentleman. He was a social drinker.
He had a past medical history of hypertension, diabetes, hyperlipidemia, gout, atrial fibrillation, and a resected olfactory neuroblastoma in remission.
He presented with a 3-year history of insidious onset language and memory impairment. The cognitive symptoms had progressed to impact his activities of daily living.
He was admitted for a left knee gouty attack. He had undergone a scheduled surgery for the known frontal sinus mucocele during the same admission. The clinical course was complicated by delirium, with stepwise deterioration after the intervention under generalized anesthesia.
Physical examination
General examination demonstrated a disoriented patient.
Neurological examination was normal. There were no focal neurological deficits nor signs of Parkinsonism.
Investigations
A metabolic screening, contrast MRI brain, electroencephalogram and lumbar puncture were unrevealing.
Thought process
This was a syndrome of delirium associated with acute medical illness on a background of chronic progressive cognitive impairment.
The pathology was likely localized to the cerebral level.
The etiology was commonly toxic-metabolic. The possibility of antibiotics-related neurocognitive side effects was entertained, but the odds was deemed to be low.
The presentation was less likely attributable to a primary neurological disorder of infective, inflammatory, neoplastic, or paraneoplastic etiology at this juncture.
Next steps
Clinical monitoring for the resolution of delirium was warranted.
Further workup with advanced imaging or novel biomarkers will be required if atypical features appear along the clinical trajectory of the underlying dementia syndrome.