Case of a 57-year-old woman with acute confusion and inability to recognize her husband

Patient is a 57-year-old Hispanic female with a past medical history of hypertension, asthma, and type II diabetes mellitus who presented to the emergency room (ER) for evaluation of 7 days of altered mental status. Upon initial presentation, the patient had difficulty following one step commands and was not fully oriented. Additionally, she appeared to be responding to external auditory and visual stimuli. Magnetic resonance imaging (MRI) completed in the ER was without acute intracranial abnormality (Figure 1), and electroencephalogram (EEG) was significant for diffuse slowing but no epileptiform activity was noted. She was admitted to the neurology service for further workup and treatment for possible autoimmune encephalitis, plasma exchange (PLEX), high-dose steroids, as well as intravenous immunoglobulin (IVIG) treatments. However, despite treatments, the patient continued to remain altered. Therefore, psychiatry was consulted as well as a cognitive specialist. Per patient's husband, he was able to recall that she had in fact had several years of cognitive decline, periods of altered mental status, hallucinations, and slowed gait. During her admission she had periods of not recognizing her husband, and identified him as an imposter, consistent with Capgras syndrome.¹ Given clinical findings, our cognitive team determined the patient's most likely diagnosis and started her on rivastigmine 1.5 mg bid with improvement.²

Lewy body dementia.