Case Reports
References I. Jabaily J. lIand H. Laszlo J. el al: Neurologic manifestations of essential thrombocythemia. Ann Imern Med 99:513-518. 1983 2. Preston F. Emmanuel I. Winfield D. et al: Essential thrombocythemia and peripheral gangrene. BM} 3:548-552. 1974 3. Wu K: Platelei hyperaggregabilily and lhrombosis in patients with thrombocythemia. Ann Intern MI'd 88:7-II. 1978 4. Olivarius B: Cerebral manifestations in thrombocythemia. ACIa Psychialrica Neurololiica Scandinal'ica 32:7782. 1957 5. Levine J. Swanson P: Idiopathic thrombocytosis: a lreat-
6.
7. 8.
9.
able cause of transient ischemic attacks. NeurololiY 18:711-713.1968 Korenman G: Neurologic syndromes associated with primary thrombocythemia. MI Sinai} Med 36:317-323. 1969 Singer G: Migrating emboli of retinal aneries in thrombocythemia. Br} Ophthamol 53:279-281. 1969 Mundall J. Quintero P. Von Kaulla K. et al: Transient monocular blindness and increased platelet aggregability treated wilh aspirin. Neurology 22:280-285. 1972 Singh A. Wetherley-Mein G: Microvascular occlusive lesions in primary thrombocythemia. Br } Haematol 36:553-564.1977
Frontal Lobe Dysfunction From Meningeal Sarcoidosis MARIO
F.
MENDEZ, M.D.
BETH ZANDER, B.A.
F
rontal lobe disorders can result in apathy, disinhibition, or other personality changes that may be mistakenly attributed to nonorganic psychological conditions. I The differential diagnosis of these disorders usually includes dementias, head injuries, and other nontreatable conditions that predominately affect the prefrontal cortex. We report on a patient with frontal lobe dysfunction due to an isolated sarcoid granuloma overlying the left frontal lobe, who improved with steroid therapy.
through on daily school assignments. Her husband also observed that this previously meticulous homemaker was no longer concerned with housework, failed to complete any non-rolJtine tasks, was irritable, and had a decreased amount of speech. The patient denied any behavioral or neurological problems. Her mental status examination was normal except for aspontaneity, decreased verbal output, and poor sequencing ability on the Luria Palm-Side-Fist Alternating Task. There were no frontal lobe release signs or other neurological abnormalities. Magnetic resonance imaging (MRI) of the head showed an enhancing lesion overlying the frontal lobes, panicularly on the left, with mass effect effacing the sulci (see Figure I). A biopsy of the lesion
Case Report A 52-year-old black woman was referred for a neuropsychiatric evaluation because of a 2- to 3-week alteration in her usual behavior as a schoolteacher and homemaker. Her co-workers reponed that she did less teaching of familiar material, avoided teaching unfamiliar material, lost interest in interacting with students and teachers, and did not follow VOLUME 33· NUMBER 2· SPRING 1992
Received July 12. 1990; revised February II. 1991; accepted February 19. 1991. From the Depanment of Neurology. University of Minnesota; and 51. Paul-Ramsey Medical Center. Address reprint requests to Dr. Mendez. Dept. of Neurology. 51. Paul-Ramsey Medical Center. Jackson at University, SI. Paul. MN 5510 I. Copyright © 1992 The Academy of Psychosomatic Medicine.
215
Case Reports
revealed changes consistent with sarcoidosis: a thickened dura infiltrated with chronic inflammatory cells. multiple noncaseating granulomas. multiple multinucleated giant cells. and negative smears and cultures for acid-fast bacilli. An extensive search for extraneural sarcoidosis
F1(;URE I.
was negative. There were no lymphadenopathy. skin lesions, or eye findings. Calcium values, angiotensinconverting enzyme. and chest x-rays were normal. Neuropsychological tests were generally normal except for measures of executive functioning (see Table I). The patient was treated for neurosarcoido-
Magnetic resonance image of the brain (T1.weighted image after intravenous gadolinium·DTPA) showing a dural enhancing lesion over frontal convexities. predominately on the left. with atten· uation of the sulci in both frontal lobes. Left: horizontal plane. Right: coronal plane.
TABLE I. Tests of executive functioning Score Test Wisconsin Card Son Test' Number of categories Perseverative errors Stroop Test (color-word) Poneus Mazes (Vineland version; TA)' Cookie Theft Picture (words/min) Lezak Tinker Toy Test score Controlled Word Fluency Test (words) Trailmaking B (seconds to complete)
Session 1
Month 4
Month 9
40
42
2.4
30b 29 b b
14 43< 3/12< 48 63.2
16.5 b
62 4/12
References I. Jabaily J. lIand H. Laszlo J. el al: Neurologic manifestations of essential thrombocythemia. Ann Imern Med 99:513-518. 1983 2. Preston F. Emmanuel I. Winfield D. et al: Essential thrombocythemia and peripheral gangrene. BM} 3:548-552. 1974 3. Wu K: Platelei hyperaggregabilily and lhrombosis in patients with thrombocythemia. Ann Intern MI'd 88:7-II. 1978 4. Olivarius B: Cerebral manifestations in thrombocythemia. ACIa Psychialrica Neurololiica Scandinal'ica 32:7782. 1957 5. Levine J. Swanson P: Idiopathic thrombocytosis: a lreat-
6.
7. 8.
9.
able cause of transient ischemic attacks. NeurololiY 18:711-713.1968 Korenman G: Neurologic syndromes associated with primary thrombocythemia. MI Sinai} Med 36:317-323. 1969 Singer G: Migrating emboli of retinal aneries in thrombocythemia. Br} Ophthamol 53:279-281. 1969 Mundall J. Quintero P. Von Kaulla K. et al: Transient monocular blindness and increased platelet aggregability treated wilh aspirin. Neurology 22:280-285. 1972 Singh A. Wetherley-Mein G: Microvascular occlusive lesions in primary thrombocythemia. Br } Haematol 36:553-564.1977
Frontal Lobe Dysfunction From Meningeal Sarcoidosis MARIO
F.
MENDEZ, M.D.
BETH ZANDER, B.A.
F
rontal lobe disorders can result in apathy, disinhibition, or other personality changes that may be mistakenly attributed to nonorganic psychological conditions. I The differential diagnosis of these disorders usually includes dementias, head injuries, and other nontreatable conditions that predominately affect the prefrontal cortex. We report on a patient with frontal lobe dysfunction due to an isolated sarcoid granuloma overlying the left frontal lobe, who improved with steroid therapy.
through on daily school assignments. Her husband also observed that this previously meticulous homemaker was no longer concerned with housework, failed to complete any non-rolJtine tasks, was irritable, and had a decreased amount of speech. The patient denied any behavioral or neurological problems. Her mental status examination was normal except for aspontaneity, decreased verbal output, and poor sequencing ability on the Luria Palm-Side-Fist Alternating Task. There were no frontal lobe release signs or other neurological abnormalities. Magnetic resonance imaging (MRI) of the head showed an enhancing lesion overlying the frontal lobes, panicularly on the left, with mass effect effacing the sulci (see Figure I). A biopsy of the lesion
Case Report A 52-year-old black woman was referred for a neuropsychiatric evaluation because of a 2- to 3-week alteration in her usual behavior as a schoolteacher and homemaker. Her co-workers reponed that she did less teaching of familiar material, avoided teaching unfamiliar material, lost interest in interacting with students and teachers, and did not follow VOLUME 33· NUMBER 2· SPRING 1992
Received July 12. 1990; revised February II. 1991; accepted February 19. 1991. From the Depanment of Neurology. University of Minnesota; and 51. Paul-Ramsey Medical Center. Address reprint requests to Dr. Mendez. Dept. of Neurology. 51. Paul-Ramsey Medical Center. Jackson at University, SI. Paul. MN 5510 I. Copyright © 1992 The Academy of Psychosomatic Medicine.
215
Case Reports
revealed changes consistent with sarcoidosis: a thickened dura infiltrated with chronic inflammatory cells. multiple noncaseating granulomas. multiple multinucleated giant cells. and negative smears and cultures for acid-fast bacilli. An extensive search for extraneural sarcoidosis
F1(;URE I.
was negative. There were no lymphadenopathy. skin lesions, or eye findings. Calcium values, angiotensinconverting enzyme. and chest x-rays were normal. Neuropsychological tests were generally normal except for measures of executive functioning (see Table I). The patient was treated for neurosarcoido-
Magnetic resonance image of the brain (T1.weighted image after intravenous gadolinium·DTPA) showing a dural enhancing lesion over frontal convexities. predominately on the left. with atten· uation of the sulci in both frontal lobes. Left: horizontal plane. Right: coronal plane.
TABLE I. Tests of executive functioning Score Test Wisconsin Card Son Test' Number of categories Perseverative errors Stroop Test (color-word) Poneus Mazes (Vineland version; TA)' Cookie Theft Picture (words/min) Lezak Tinker Toy Test score Controlled Word Fluency Test (words) Trailmaking B (seconds to complete)
Session 1
Month 4
Month 9
40
42
2.4
30b 29 b b
14 43< 3/12< 48 63.2
16.5 b
62 4/12
