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Endgames Case Review

An older man with memory impairment and convulsions

BMJ 2017; 358 doi: (Published 05 July 2017) Cite this as: BMJ 2017;358:j2824
  1. Xiu-he Zhao, associate professor,
  2. Yi-ming Liu, professor,
  3. Xue Yang, attending doctor,
  4. Shu-zhen Wang, professor,
  5. Sheng-jun Wang, associate professor
  1. Department of neurology, Qilu Hospital, Shandong University, Ji’nan, China
  2. Correspondence to X Wang

A 62 year old man was admitted to hospital with a one month history of convulsions and confusion without fever. He had seizures, memory impairment, and changes in behaviour, sometimes becoming irritated and aggressive. He had no history of alcohol or drug misuse.

Neurological examination showed impairment to memory and cognition, orientation, calculation, and attention abilities. The patient’s Glasgow coma scale score was 13.

Blood tests including full blood count, glucose, serum electrolytes, ammonia, lactate, renal function, and liver function were normal. Tests for infectious and autoimmune conditions were requested.

Analysis of the patient’s cerebrospinal fluid showed normal cytology, with a slightly increased protein level. An electroencephalography exam showed low amplitude slow waves in the temporal lobes. Magnetic resonance imaging (MRI) of the brain showed abnormalities in the bilateral medial temporal lobes (fig 1, A). Based on the imaging findings, blood tests were requested. The patient’s serum anti-thyroid peroxidase level was raised, and the gamma-aminobutyric acid receptor B (GABABR) antibody was positive, both in the serum and cerebrospinal fluid. Tests for anti-onconeural antibodies, including antineuronal nuclear autoantibody type 1 (anti-Hu), antineuronal nuclear autoantibody type 1 (anti-Ri), and Purkinje cell cytoplasmic autoantibody type 1 (anti-Yo), were negative. In addition, thorax computed tomography (CT) showed a nodule in the left lung with lymph …

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