Anisocoria leading to the cause of cognitive decline: a case report

Dementia is an increasingly common condition. Although Alzheimer’s disease represents the most common form, there are many other types requiring a careful diagnostic evaluation. Our aim was to report the case of a geriatric patient with cognitive impairment and rapid functional loss. MATERIALI E METODI: The patient was an 82-year old man, with arterial hypertension, diabetes, chronic heart disease, and history of prostate cancer. He was in stable and relatively healthy condition up to one month before the first assessment at our outpatient clinic, where he was referred for the sudden onset of aspecific symptoms (including apraxia, slow walking, and anxiety). RISULTATI: He presented almost complete dependency in the activities of the daily living (Basic Activities of Daily Living 1/6, Instrumental Activities of Daily Living 1/8), initial memory disturbances (Mini Mental State Examination 23/30), and compromised mobility (Performance Oriented Mobility Assessment 17/28). The blood tests and apolipoprotein E genotyping were normal. Treponema pallidum antibodies were also negative. Our preliminary hypothesis, supported by the cardiovascular risk profile, the report of a recent brain MRI scan (documenting chronic vascular encephalopathy), and the neurologic examination, was of vascular dementia. Nevertheless, the presence of anisocoria found during the follow-up visit led us to repeat a neuroimaging evaluation (brain CT), which documented an area of hyperdensity surrounding the left lateral ventricle frontal horn, suggestive for lymphoma. This finding was confirmed by a brain MRI with contrast. Total body PET scan described the signs of a systemic lymphoma. The patient underwent hematological evaluation, which advised for palliative care with steroid therapy. CONCLUSIONI: In our case, the cognitive impairment presented by the patient was complicated by the sudden onset of a vague symptomatology. Despite the availability of a previous neuroimaging test (first brain MRI), our case found solution thanks to the onset of an often overlooked sign (i.e., anisocoria). This made us repeat further neuroimaging, which led to the probable cause of the functional decline.