Case 26-2020: A 60-Year-Old Woman with Altered Mental Status and Weakness on the Left Side (original) (raw)

2020, New England Journal of Medicine

A 60-year-old woman presented to this hospital with altered mental status during the pandemic of coronavirus disease 2019 (Covid-19), the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The patient had been in her usual state of health until 1 week before admission, when cough and headache developed. One day before admission, vomiting and diarrhea developed. That day, the patient was last seen by her husband at 3:00 p.m. before she went to sleep. The husband reported that the patient awoke screaming at 1:00 a.m. on the day of admission, and emergency medical services (EMS) were called. When EMS personnel arrived, the patient was reportedly lethargic and unable to answer questions. The blood glucose level, obtained by fingerstick testing, was 60 mg per deciliter (3.3 mmol per liter; reference range, 70 to 110 mg per deciliter [3.9 to 6.1 mmol per liter]). Intravenous dextrose was administered. A repeat fingerstick glucose measurement was 127 mg per deciliter (7.0 mmol per liter), and the lethargy abated. The patient was brought by EMS personnel to the emergency department of this hospital. In the emergency department, the patient reported weakness on the left side of her body and persistent headache. She reported that when she had awoken at 1:00 a.m., she was unable to move or speak, was afraid she was going to die, and began screaming for help. She reported no aura, urinary or fecal incontinence, or neck pain. She had recently moved from Puerto Rico and lived in a suburb of Boston. She did not speak English and was marginally housed, sleeping in the living room of a friend's apartment with her husband. Several people living in the apartment had had cough and fever. The patient had a history of diabetes mellitus, hypertension, and schizophrenia. Medications included aspirin, glipizide, hydrochlorothiazide, lisinopril, and risperi