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RESIDENT FELLOW SECTION Section Editor Mitchell S.V. Elkind, MD, MSClinical Reasoning: Progressive visuospatial complications within 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 having a 3-month history of progressive cognitive impairment. Six weeks ahead of presentation, he became unable to use his mobile phone, with difficulties pressing the digits inside the correct order. He had created troubles reading, describing a jumbledup appearance of words on the web page. He omitted single letters when writing, and had difficulty in using cutlery and accurately judging portion sizes. He had ceased driving as a result of navigational problems and due to repeatedly hitting the curb. Inside the last four weeks, he had developed difficulty dressing. Notably, he had good insight, becoming able to provide 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). 1 year later, following an exacerbation of joint symptoms as well as the improvement of interstitial lung illness thought to be a systemic complication of RA, his methotrexate dose was elevated to 25 mgwk (subcutaneously) and leflunomide (ten mgd) was added. At presentation, he remained on methotrexate and hydroxychloroquine at the similar doses, but leflunomide had been discontinued and.
