68 Marienfeld: Expressive aphasia presentation of B. henselae encephalitis Figure 1. CT scan without contrast. Low- density lesion in the region of the left in- sula, with well-defined borders and no mass effect. plications and often no need for antibiotics [1,5]. Diagnosis is usually based on sero- logic tests used in the appropriate clinical setting, though PCR of tissue specimens is sometimes helpful [6,7]. CASE A 59-year-old man presented with the sudden onset of speech difficulties. He re- ported no other associated symptoms such as headache, dysarthria, dysphagia, weak- ness, paresthesias, or difficulty understand- ing speech. Additional history was remarkable for a left frontal stroke in March 2007 that presented with mutism and no other deficits. He had recently adopted sev- eral stray kittens. Ten days prior to presenta- tion, he had a skin infection that progressed to right axillary lymphadenopathy, for which he received a five-day course of doxycy- cline. The initial examination, two hours after the onset of speech difficulties, revealed an afebrile man with a painless 4mm erythema- tous papule with a central scab on his right forearm. His neurologic exam was remark- able for an expressive aphasia, word substi- tution errors, and impaired repetition. A head CT in the emergency department showed a Figures 2a (left) and b. Axial and coronal flair sequences. Hyperintensity centered on the insula, without mass effect. Figure 2c. Diffu- sion-weighted image. No acute findings; specifi- cally, no sugges- tion of recent infarction. Figures 2d (left) and e. Pre- and post-con- trast T1-weighted axial scans. No enhance- ment in the region noted to be abnormal on the FLAIR sequences. The entire series of images, including the FLAIR, diffusion, and post-contrast images, are not consistent with an acute or subacute infarction. low-density lesion in the region of the left insula, with well-defined borders and no mass effect (Figure 1). The following morn- ing, the patient had an MRI of the brain that showed his prior stroke but no areas of acute ischemia (Figures 2a-e). An EEG showed moderate generalized slowing with no epileptiform activity. The aphasia fluctuated between making paraphasic errors and a frank expressive aphasia, and he was becoming more con- fused. Shortly after his EEG and approxi- mately 18 hours from the onset of symptoms,