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RESIDENT FELLOW SECTION Section Editor Mitchell S.V. Elkind, MD, MSClinical Reasoning: Progressive visuospatial problems 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 with a 3-month history of progressive cognitive impairment. Six weeks just before presentation, he became unable to use his mobile phone, with troubles pressing the digits within the right order. He had developed challenges reading, describing a jumbledup look of words on the web page. He omitted single letters when writing, and had difficulty in applying cutlery and accurately judging portion sizes. He had ceased driving due to navigational complications and because of repeatedly hitting the curb. Within the final four weeks, he had created difficulty dressing. Notably, he had great insight, becoming able to offer a detailed description of symptoms. Four years earlier, the patient had been diagnosed with rheumatoid arthritis (RA) and commenced immunomodulatory therapy with IL-6 Protein Biological Activity methotrexate (15 mgwk plus folic acid five mgwk) and hydroxychloroquine (200 mgd). One particular year later, following an exacerbation of joint symptoms and also the development of interstitial lung disease believed to become 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 in the identical doses, but leflunomide had been discontinued and.
