Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Autonomic Disorders

Clinical Vignette A 65-year-old man presented with subacute onset of severe, unexplained orthostatic dizziness and light-headedness. Over the next 2 months, he developed dry mouth, dry eyes, urinary hesitancy, erectile dysfunction, and severe constipation. His previous medical history was unremarkable. His only medication was aspirin. He smoked one pack per day and drank sparingly. His family history was noncontributory. The patient's blood pressure was 124/76 mm Hg…

Paraneoplastic Neurologic Disorders

Paraneoplastic neurologic disorders are seen when antitumor immunologic responses, primarily antibodies, directed against antigens expressed in the cancer, attack neural cells (neurons or glia) also expressing these antigens. Based on the neurologic presentation and the antibody profile, there are numerous well-defined paraneoplastic syndromes such as limbic encephalitis with small cell lung cancer (SCLC) and seropositivity for ANNA-1 (anti–neuronal nuclear antibody type-1 [Hu]); stiff person syndrome with…

Spinal Cord Tumors

The most common spinal cord tumors are metastatic extradural lesions most commonly occurring in patients with already identified systemic cancers. Their presentation is often relatively acute, usually associated with focal back and/or radicular pain. On occasion, these lesions are the initial clinical manifestation of a heretofore unsuspected systemic malignancy. In contrast, primary intradural spinal cord tumors occur infrequently; typically their presentation is a relatively subtle one,…

Brain Tumors

Clinical Vignette A 47-year-old self-employed father presented to the emergency department having difficulty discriminating coins in his pocket. He had been skiing that day and was concerned enough to seek medical attention on his way home. His general health was excellent. The only abnormality on his neurologic examination was confined to his right hand. Here he demonstrated loss of two-point discrimination in his fingers as well…

Infections in the Immunocompromised Host

Immunocompromised hosts are susceptible to a wide range of neurologic infections, which include both opportunistic infections and those typically found in normal hosts. The risk for particular infections is related to a number of factors including the type of immune suppression, the duration of immune compromise, and geographic or epidemiologic risk factors. For example, the infection risk profile of a human immunodeficiency virus and acquired immunodeficiency…

Neurosarcoidosis

Sarcoidosis is a multisystem granulomatous autoinflammatory disorder that typically affects lungs, lymph nodes, and skin. The nervous system is involved in 5% to 20% of patients with sarcoidosis. Neurosarcoidosis (NS) has a predilection for the meninges (resulting in cranial neuropathies and radiculopathies), pituitary gland, hypothalamus, and orbital apex but can involve any level of the neuraxis including the brain parenchyma, cerebellum, spinal cord, peripheral nerves, and…

Parasitic and Fungal Disorders and Neurosarcoidosis

Parasitic infections of the nervous system range from acute syndromes such as diffuse cerebritis in cerebral malaria to more chronic mass lesions causing seizure disorders such as neurocysticercosis. This chapter will focus on the most common parasites causing central nervous system (CNS) infections. Cerebral Malaria Clinical Vignette A 45-year-old previously healthy Indian male working as an engineer in the United States returned from India in August…

Viral Diseases

Herpes Simplex Encephalitis Clinical Vignette An independent 74-year-old man left a family wedding reception early because he did not feel well; he complained of mild nausea and general malaise. His daughter called the next day, and when he did not answer the phone, she went to his home to check on him, discovering him wandering in his backyard acutely confused. She convinced him to go to…

Bacterial Diseases

Common Syndromes Bacterial Meningitis Clinical Vignette A 19-year-old woman presented to the emergency department with confusion, lethargy, and neck stiffness. Her dorm mates reported that she had experienced upper respiratory symptoms for 3 or 4 days before presentation. She had no significant past medical history. On physical examination, her findings were temperature, 98.6° F (37°C); pulse, 100 beats/min; respirations, 20/min; and blood pressure, 110/70 mm Hg. Although…

Alcohol and Drug Abuse and Dependence

Clinical Vignette A 73-year-old woman is seen in the emergency department after an unwitnessed fall at home in which her husband heard a crash and found her moments later on the ground in her bedroom. She was disoriented and bleeding from a head laceration that occurred when she fell and hit the corner of their bedroom dresser. She has a past medical history of anxiety, obesity,…

Other Psychiatric Disorders

The recognition and treatment of mental disorders are not confined to the specialty of psychiatry. Neuropsychiatric symptoms can mimic those of nonpsychiatric disorders that bring the patient to the attention of the nonpsychiatrist. This chapter reviews a number of important conditions that should be recognized in the nonpsychiatric setting because they are common, serious, and often overlooked: somatic symptom disorder, attention-deficit/hyperactivity disorder, panic disorder, posttraumatic stress…

Mood and Psychotic Disorders

Mood and psychotic disorders account for a substantial burden of mental disease. These disorders are often first evaluated in primary care offices or emergency departments. This chapter will focus on a selection of these commonly encountered disorders: major depressive disorder, persistent depressive disorder, bipolar disorder, and schizophrenia. Major Depressive Disorder Clinical Vignette A 69-year-old man was brought to the emergency room by his family for evaluation…

Other Central Nervous System Demyelinating Disorders

Neuromyelitis Optica (Devic Disease) and Neuromyelitis Optic Spectrum Disorder Clinical Vignette A 58-year-old woman was admitted to the hospital with a 5-day history of numbness and weakness in both lower extremities, a tight bandlike sensation across her chest associated with gait difficulties, and urinary urgency. The patient had similar but less severe symptoms 1 year prior that resolved within a few weeks. She did not seek…

Multiple Sclerosis

Incidence Multiple sclerosis (MS) is the most common chronic disabling immunologic disease of the central nervous system among young people, typically presenting in the third to fifth decades of life, affecting women more than men. It is estimated that approximately 2.5 million individuals around the world have MS, more than 400,000 of them in the United States. Multiple sclerosis is more prevalent in northern latitudes, and…

Gait Disorders

Clinical Vignette A 70-year-old woman presented with a 2-year history of gait slowness and unsteadiness. She sustained several falls, usually backward. She began using a cane 1 year ago. She has noticed difficulty standing up or getting out of her car. Her husband described her walking as if “her feet are glued to the floor.” In addition to her gait difficulties, she has developed urinary frequency…

Surgical Treatment of Movement Disorders

Medical treatment of movement disorders continues to be effective but has substantial limitations. For decades, the surgical treatment of movement disorders centered around the creation of lesions within the brain. Developments in technology made neuromodulation, in the form of deep brain stimulation (DBS), a more attractive option for many patients. Advantages of DBS include the ability to modulate the degree of stimulation over time, allowing for…

Psychogenic Movement Disorders

Clinical Vignette A 25-year-old swimming champion presented with sudden onset of gait disturbance and tremor. She presented to the clinic with her boyfriend and mother. On examination, she walked slowly and gingerly with her arms held out and fell repeatedly in the arms of her boyfriend who shadowed her for fear that she would fall and injure herself. She also exhibited tremor which appeared when arms…

Medication-Induced Movement Disorders

Clinical Vignette A 52-year-old Caucasian woman presented to a psychiatrist with her first manic episode. Patient had never been treated with any antipsychotic medication in her life. During the current episode, she was treated with aripiprazole 30 mg During a follow-up visit 3 months later, the patient was found to have developed involuntary orofacial movements. She was not taking any other antipsychotic or antidopaminergic medications. The patient's…

Tic Disorders

Clinical Vignette A 9-year-old boy presented to the neurology clinic with 1 year of excessive eye blinking. He was accompanied by his parents. His past medical history was unremarkable; he was born at term and reached all developmental milestones appropriately. Schoolwork has been average; he frequently loses pencils and articles of clothing. He has difficulty finishing his homework. During the past year, his parents have noticed…

Myoclonus

Clinical Vignette A 73-year-old, right-handed man with history of coronary artery disease, myocardial infarction, peripheral vascular disease, and hypertension presented with cardiac arrest followed by resuscitation with subsequent development of anoxic brain injury. He was seen by a neurologist in the intensive care unit (ICU) setting 1 week after his cardiac arrest. His family was very concerned about constant “jerkiness” of his body. Those movements seemed…