A 65 year-old male transferred to The Johns Hopkins Hospital for change in mental status associated with fever.

The patient has a past medical history of Diabetes Mellitus type II controlled with oral medication, hypertension, peripheral vascular disease status post left big toe amputation, and alcohol abuse. He has had multiple episodes of confusion, disorientation and syncope in the last 5 years, thought to be alcohol related. A cardiac workup was negative. Mini mental exam was 22/30 and he was diagnosed with dementia in 1999. He was placed in a nursing home secondary to dementia. Since that time he has had progressive decline in neurologic status becoming more withdrawn and less responsive. His wife notes that he no longer remembers many family members. He is generally cooperative but often has outbursts of anger and frustration. He was able to feed himself at the nursing home.

One week prior to admission (early January 2002), he developed a new fever and decreased p.o. intake. His wife felt that his mental status had further declined and hence he was transferred to The Johns Hopkins Hospital for further care.

Alcoholism
Diabetes Mellitus type II
Gastroparesis
Hypertension
History of bilateral hip avascular necrosis
Gastroesophageal reflux disease
Raynaud’s disease
Prurigo nodularis

Bilateral femoral-to-popiteal bypasses
Stab wound to right flank
Left big toe amputation
Right index finger amputated

Longstanding history of alcohol abuse
Smokes cigarettes

Insulin sliding scale, Folate, Lipitor, Metformin, Multivitamins, Zantac, Trazadone, Amitriptyline, Aspirin, Avalide

Vital signs: T 103.8F in the emergency room, BP 98/43, P 96, RR 24 (sat 89% on room air)
Head/Neck: Poor dentition, no nuchal rigidity, no carotid bruit, JVP was flat with no lymphadenopathy
Chest: Right basilar bronchial breath sounds and crackles
Cardiovascular: Tachycardia with no murmurs, rubs or gallops, regular rate and rhythm, normal S1, S2
Abdomen: No hernia, slightly distended, positive bowel sounds, non-tender and tympanic on percussion
Extremities: Right index finger, left big toe amputated and a right arm tattoo
Neurological: awake but only able to identify name, Baltimore. Speech was slow but comprehensible. Cooperated with simple commands but could not complete complex instructions, no resting tremor or extremity rigidity, cranial nerves normal, strength normal and symmetric, decreased light touch sensation at the feet/ankles, unable to cooperate with cerebellar testing and gait. Mini-mental 10/30.

Chemistries were normal except BUN/creatinine= 26/1.2; serum glucose = 145 mg/dl. His white count was 18.3 with 85% neutrophils, hematocrit 41.4 and platelets 145,000.

Chest x-ray: Right costophrenic blunting

MRI (selected axial FLAIR images) from 2000 shows diffuse cerebral volume loss including the temporal lobes. No prominent small vessel ischemic changes, no intracranial mass (Figure 1).

CT (brain, without contrast) from 2002 shows similar findings, with no acute intracranial abnormality (Figure 2)

Echocardiogram: Sinus tachycardia with early repolarization, no change from baseline

After admission to The Johns Hopkins Hospital in January 2002, an infectious workup was performed. Blood and urine cultures were negative. He was started on broad-spectrum antibiotics and Tylenol, and his temperature fell to 99.7F. Mental status was improving. He was alert and oriented x2. Two days after admission, the patient was found to have no pulse or blood pressure. Given his DNR/DNI status, he was not coded and pronounced at that time. An autopsy was performed.

What is the differential diagnosis for this patient’s dementia?

What was the cause of his decreased mental status prior to admission?