60 year old female with schizoaffective disorder on clozapine and lithium + other meds who is pretty functional and relatively normal at baseline. Has a one week history of episodes of weakness, "spasms" and falls. Comes into the ED with AMS, dysarthria and weakness. Afebrile. 3-4/5 strength.
Head CT and MRI are negative. Labs negative, except elevated wbc (but chronic, over 2 decades of lymphocytosis). Chest x ray shows ground glass opacities b/l. Urine is normal.
Treated with antibiotics for possible pneumonia. Rispideral discontinued, benzos discontinued.
Over the next week, patient waxes and wanes but is confused intermittently and cannot ambulate. Forgets questions etc. Strength is more 4/5-5.
More testing is done. CRP/ESR are normal. Rheum tests return normal except very positive ANA and positive ANCA. Anti-tpo negative. TSH wnl, on levo for hx of hypoT. HepC,HIV,HepB negative. Lithium levels normal. Clozapine level returns quite high, which could be an explanation but patient waxes and wanes + a dose was held with no relief.
EEG shows encephalopathy. LP is pending, cant get consent.
What's your differential with this patient at this point?
Head CT and MRI are negative. Labs negative, except elevated wbc (but chronic, over 2 decades of lymphocytosis). Chest x ray shows ground glass opacities b/l. Urine is normal.
Treated with antibiotics for possible pneumonia. Rispideral discontinued, benzos discontinued.
Over the next week, patient waxes and wanes but is confused intermittently and cannot ambulate. Forgets questions etc. Strength is more 4/5-5.
More testing is done. CRP/ESR are normal. Rheum tests return normal except very positive ANA and positive ANCA. Anti-tpo negative. TSH wnl, on levo for hx of hypoT. HepC,HIV,HepB negative. Lithium levels normal. Clozapine level returns quite high, which could be an explanation but patient waxes and wanes + a dose was held with no relief.
EEG shows encephalopathy. LP is pending, cant get consent.
What's your differential with this patient at this point?
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