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RESIDENT FELLOW SECTION Section Editor Mitchell S.V. Elkind, MD, MSClinical Reasoning: Progressive visuospatial difficulties inside a 71-year-old manSECTIONMkael Symmonds, PhD, MRCP Wilhelm K er, PhD, FRCR Ursula G. Schulz, DPhil, FRCPCorrespondence to Dr. Symmonds: mkael.symmondsndcn.ox.ac.ukA 71-year-old right-handed man presented using a 3-month history of progressive cognitive impairment. Six weeks prior to presentation, he became unable to utilize his mobile telephone, with troubles pressing the digits inside the correct order. He had created issues reading, describing a jumbledup appearance of words around the page. He omitted single letters when writing, and had difficulty in employing cutlery and accurately judging portion sizes. He had ceased driving resulting from navigational issues and as a result of repeatedly hitting the curb. In the final four weeks, he had developed difficulty dressing. Notably, he had good insight, getting able to give a detailed description of symptoms. Four years earlier, the patient had been diagnosed with rheumatoid arthritis (RA) and commenced immunomodulatory therapy with methotrexate (15 mgwk plus folic acid 5 mgwk) and hydroxychloroquine (200 mgd). One particular year later, following an exacerbation of joint symptoms plus the improvement of interstitial lung illness thought to be a systemic complication of RA, his methotrexate dose was improved to 25 mgwk (subcutaneously) and leflunomide (ten mgd) was added. At presentation, he remained on methotrexate and hydroxychloroquine at the identical doses, but leflunomide had been discontinued and.
