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A case of confusion and bilateral temporal lesions in a young woman

A 43-year-old right-handed woman with a medical history significant for methamphetamine abuse was admitted after presenting with a rapidly worsening confusion. The patient's family described 3 weeks of progressive disorientation, memory problems, anorexia with weight loss, and bilateral lower extremity neuropathic pain. Her only other pertinent medical history included a 10-pack-year history of tobacco use.

On examination, her vital signs were normal except for a sinus tachycardia. She scored 15/30 on the Mini-Mental State Examination with loss of points primarily on orientation, recall, and attention. There were no abnormalities of her cranial nerves, motor examination, coordination, or gait. Sensory examination demonstrated mild hypoesthesia over her feet, otherwise normal.

Initial laboratory values included a normal complete blood count, complete metabolic panel, and negative rapid plasmin reagin, HIV, and antinuclear antibodies. She had a positive toxicology screen for methamphetamine and a low-normal vitamin B12 level of 282. Her CSF analysis …