Clinical Reasoning: A young adult presents with focal weakness and hemorrhagic brain lesions

Abstract

A 25-year-old man who emigrated from Mexico 5 years ago presented with headache, altered mental status, and left hemiparesis. Initial history obtained from collateral sources indicated the patient had complained of a headache of increasing severity for the past 2 months. Two weeks prior to presentation, he experienced malaise, decreased appetite, nausea and vomiting, visual changes, and gait difficulties resulting in 2 falls. The day of presentation, he developed acute onset left upper and lower extremity weakness prompting emergency evaluation. On arrival he was lethargic, disoriented, and did not follow commands. Following intubation in the emergency department, he was transferred to the neurologic intensive care unit (ICU). He was febrile and tachycardic on arrival to the ICU. Upon cessation of sedation, the patient was ill-appearing but awake and able to cooperate with the neurologic examination. He was oriented to hospital name and year and was able to follow one-step commands. His pupils were equal, round, and reactive to light and accommodation. Bedside funduscopic examination showed normal discs and vessels. His extraocular movements were full except for the inability to adduct his right eye. He blinked to threat bilaterally but had left-sided visual neglect with a right gaze preference. He had left lower facial weakness. On motor examination, he had left flaccid paralysis as well as mild decreased strength in his right upper and lower extremities (4+/5) that might have been attributable to incomplete cooperation. Sensation was intact to light touch on the right but only to noxious painful nail bed stimulation on the left. Reflexes were brisk on the right and diminished on the left. He had a left Babinski sign. Head CT revealed 2 foci of hemorrhage in the right frontal and parietal lobes with associated vasogenic edema (figure 1). Figure 1 CT findings Two foci of hemorrhage are …