Case Presentation
A 74-year-old, right-handed male was admitted with complaints of jaw and bilateral hand movements for 3 months and rapidly progressive dementia for 1 month, coupled with intermittent visual hallucinations and raving.
Physical Examination
- On admission, a neurologic examination indicated prominent cognitive impairment and psychiatric symptoms.
- Particularly, he failed to complete the Mini-Mental State Examination (MMSE) and had a neuropsychiatric inventory (NPI) score of 50.
- Magnetic Resonance imaging indicated ischemia within the periventricular area and centrum semiovale.
- The haematological screening was unremarkable, including a routine blood test, tumour marker, biochemistry, folate, vitamin B12, and thyroid function.
- A routine cerebrospinal fluid (CSF) test demonstrated normal pressure, leukocytosis, glucose, and chlorine but mildly elevated protein levels.
- A video electroencephalogram indicated increased slow activities without epileptic discharge.
Medical History
- His past medical history was traced back to 5 years ago when he suffered from rectal carcinoma and received surgery and chemotherapy.
Clinical Examination
- The patient exhibited multiple involuntary movements (jaw tremors, motor tremors of hands), his hands always groped about, and would fall backward when he was walking or seated.
- He could not recognize his family or location.
- The patient also experienced aberrant motor behaviour and night-time behaviour.
Treatment
- Olanzapine 2.5 to 5 mg per night and was administered pramipexole and compound levodopa.
- The patient was also treated with immunotherapy, including intravenous immunoglobulin 0.4 g/kg per day for 5 days followed by intravenous methylprednisolone pulse therapy 500 mg per day for 5 days.
- Methylprednisolone was decreased to 80 mg per day and mycophenolate mofetil 500 mg was administered twice a day.
Clinical Outcome
- On the 9th day of immunotherapy, the patient was cooperative for MMSE evaluation and an improvement in orientation, immediate recall and naming, and repetition function