ACUTE GLOBAL AMNESIA WITH HYPERDENSITIES OF BILATERAL TEMPORAL LOBES

Purpose: Case presentation of a 31 year old female with a past medical history of diabetes, hyperlipidemia, and vitiligo who presented with an acute global amnesia and hyper-densities of bilateral temporal lobes. A unique case and the lessons learned. Methods: Medical charts, Diagnostic studies, Imaging studies, Lumbar puncture and Laboratory studies, Consultant notes and referral notes. Results: This case is a journey into the process of elimination as well as trial and error. From laboratory draws for blood; looking for serology, immunologic markers, and complete blood differentials; to imaging studies showing minor arcuate infarcts on CT, and ominous hyper-densities in both temporal lobes of the brain by MRI; we speculate as to the cause. This journey was one of expectant surprise. Acyclovir was prophylactically used to circumvent a herpetic encephalitis. Soon it was found to be unnecessary as the lumbar puncture showed herpes to be an unlikely source. As the days progressed, it became evident that our advanced diagnostic abilities were not satisfactory. The patient did not get better. In the end, after performing lumbar punctures, additional imaging of the blood vessels, and continued laboratory draws in search of an answer; our patient grew weary. A decision to recommend a brain biopsy was presented much too late. The patient decisively declined. Conclusions: As physicians, we want to get to the bottom of any medical problem. Physicians are often prompted to find the answers to patients' problems everyday. In medical texts and in pathology books, it seems so convenient. A case is presented, a trail of diagnostic study often points to the ultimate answer; the case is complete and the book can be closed. Unfortunately, in real life, people live with unsolved issues all the time. So our patient, after over a week in a confined space, decided that she no longer cares enough to find the diagnosis. She knows she cannot remember some things and that it worries her family, but she had had enough. The lesson learned here is that regardless of how severe or esoteric the problem; an expedient management of the case may have been better served. For instance, recognizing the need for a brain biopsy earlier rather than later may have elucidated a possible diagnosis. Second, it isn't the final diagnosis that matters to a patient, but the freedom to explore it if she so chooses to&or not.