Clinical Reasoning: A 27-year-old man with rapidly progressive coma

• Published in: Neurology Vol. 85; no. 9; pp. e74 - e78
• Main Authors: Wong, Jonathan M, Chandra, Mekhala, VanDeBogart, Rachael, Lu, Brandon, Yee, Alan H
• Format: Journal Article
• Language: English
• Published: 01-09-2015
• ISSN: 0028-3878; 1526-632X
• DOI: 10.1212/WNL0000000000001887

A 27-year-old man was brought to the emergency department by paramedics after being found wandering the street not communicative and with unsteady gait. At the scene, he was noted to have full body tremulousness, which improved after receiving midazolam. He was urgently transported to an emergency department and subsequently developed nausea, vomiting, and progressive deterioration of his mental status. On physical examination, he had tachycardia without fever, and was hemodynamically stable with normal oxygen saturation. He was stuporous; however, all brainstem reflexes were preserved with symmetrically reactive pupils of normal shape and size. He demonstrated spontaneous symmetrical limb movement as well as purposeful withdrawal. He had anicteric sclera, and his dermatologic evaluation showed no rash, needle track marks, or focal signs of external trauma.