Case 9: Pregnant? Who's Pregnant?: Memory Loss in a Young Woman

Constance Smith-Hicks, MD, PhD

Disclosures

May 26, 2005

Introduction

The patient is a 19-year-old, pregnant, white woman with a history of cystic fibrosis (CF), Graves' disease, acquired hearing loss, and CF-related diabetes, who presents to the hospital after being "found down," with a dextrose stick reading of 29 mg/dL.

She was last seen well the night before admission. Although she responds well to an infusion of 50% dextrose, her exam is notable for retrograde amnesia. She has no memory of the past 3 months and does not remember being told of her pregnancy at the time of her last CF-related hospitalization 5 weeks earlier. She denies fever, cough, dysuria, vaginal bleeding, headache, shortness of breath, or seizures. She is maintained on an insulin pump and recently completed a 2-week course of tobramycin and meropenem for a CF flare.

Her past medical history is as stated. Of note, she is the full-term product of an unremarkable pregnancy and developed normally. She attends Gallaudet University, Washington, DC, and is studying to become a teacher for the hearing impaired. She is a "B" student and works at a local drugstore in the film-processing department.

Her medications at the time of admission include tobramycin, albuterol, azithromycin, deoxyribonuclease (Pulmozyme), ursodiol (Actigall), pancrelipase (Ultrase), prenatal vitamins, and her insulin pump.

She has no known drug allergies.

The patient weighs 68 kg. Her heart rate is 97 beats/minute; respiratory rate, 18 breaths/minute; blood pressure, 107/69 mm Hg; and pulse oximetry is 97%.

The general exam is unremarkable. She has no dysmorphic features; her sclera is anicteric, neck supple, oropharynx clear, and she has no lymphadenopathy. Her heart rate is regular and without murmurs; mild crackles are audible at the lung bases bilaterally. Her abdomen is soft and non-distended. Although her skin is without neurocutaneous stigmata or any rash, she has significant clubbing in all her extremities.

A detailed neurologic exam, including cranial nerves, muscle strength, reflexes, sensation, cerebellar function, and gait, is unremarkable. Although her affect is flat, she is interactive and cooperative. Her Mini-Mental Status Examination (MMSE) score is 26 of 30, with points off for poor orientation to day, date, month, and place. Her speech is fluent with no language difficulty. Although she can read phrases and follow simple written directions, she has difficulty comprehending written material.

  • Blood chemistry profile, CBC: normal;

  • Albumin/total protein: 2.5/5.9 g/dL;

  • Urine toxicology: negative;

  • Dextrose stick fluctuates: 50-263 g/dL;

  • Vitamins B1, B12, A, D, and E levels: normal;

  • Electroencephalogram (EEG): normal; and

  • Cerebrospinal fluid analysis: 0 white blood cells; 1 red blood cell; glucose, 122; protein, 24; myelin basic protein immunoglobulin (Ig)G index and oligoclonal bands, negative; and enterovirus polymerase chain reaction (PCR), gram stain, and culture, negative. Cytopathology is acellular.

Results of magnetic resonance imaging (MRI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) and magnetic resonance spectroscopy (MRS) are shown in Figures 1 and 2.

Magnetic resonance imaging (dated July 14), diffusion-weighted imaging, and apparent diffusion coefficient -- an isolated, well-circumscribed area of restricted diffusion in the splenium of the corpus callosum, with a normal magnetic resonance angiogram.

Magnetic resonance spectroscopy (dated July 14) of splenium lesion is normal.

Which of the symptoms are related to the splenial lesion?

  1. Memory loss

  2. Reading comprehension difficulties

  3. Both

View the correct answer.

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