Age: 68.0
Sex: F
Vaccine: COVID19, COVID19, UNK
Symptoms: Antibody test negative, Blood folate, Blood thyroid stimulating hormone, COVID-19, CSF protein increased
Clinical narrative: On 11/07/2022 we go to the Department of Neurology.We visit Dr.,he is a board-certified neurologist at the facility. Dr. say: Thank you for allowing us to review your mother's case and provide our opinion.The goal of your Expert Medical Opinion is to confirm your mother's diagnosis, whether additional evaluation is needed,and provide treatment options.Patient is 69 years old and has recently been diagnosed with CJD.You reported to Included health that patient was healthy until this past June,2022.It was noted that she had COVID-19 in January of 2022,but records available to us do not mention any symptoms clearly starting with this infection. There is one note stating that family thought some minor difficulties with memory may have started  over this past year, but it is unclear when these difficulties may have occurred and it is agreed that symptoms become significant around June. On June 2,2022,she got lost while driving. Around  this time, family had noted that she got into two car accidents, and she began experiencing difficulty speaking clearly as well. She tried to see her primary care provider, but when she called for an appointment on 07/11/22 she could not get an appointment sooner than early August, so she was instructed to go to the Emergency Department. In the ED, she told a neurologist that she was having difficulties with her memory and she was also having blurry vision. It was thought that her problems with driving may have been due to the vision difficulties. They performed a CT scan of her head and sent screening labs ( CBC, BMP, urinalysis, COVID-19 test ), but nothing was found. She was recommended to be admitted in order to have an MRI of her brain, an EEG, and possible spinal tap but, your family and patient decided against the admission and went home. She saw her primary care provider a few days later on 07/15/2022 who referred her to a neurologist and sent more labs, which were done on 08/11/2022, including looking for syphilis, signs of other organs in her body not functioning well with a comprehensive metabolic panel  (CMP ), sings of thyroid problems with a TSH, as well as vitamin deficiencies including folate and vitamin B12. They found her B12 was low at 157  (normal >220 ). She was started on B12 supplements, both 1000 mcg solution to take by mouth each day as well as monthly injections.   She first saw her neurologist some time before 08/15/2022 according to a primary care note (we do not have a copy of that note). She had an EEG done on 08/17/2022 which showed sharp waves (abnormal waves) on both sides of the brain (in the frontal and temporal lobes). She later had an MRI on 08/22/2022 that showed the outer portion of her brain called the cortex was abnormal, which the radiologist had noted as "possible cerebritis," which means inflammation of the brain. She was then sent to the emergency department on 08/30/2022 because of these MRI findings where an MRI with contrast was done and she had a spinal tap ( lumbar puncture ). This MRI with contrast did not show any signs of "enhancement" or signs that her brain was absorbing contrast. More labs were sent while in the emergency department, which showed her B12 was repleted (greater than 2000) and that her HIV test was negative and thus not likely a cause of her symptoms. After the initial results of the spinal tap did not show any signs of infection, patient and your family decided to go home instead of being admitted to the hospital.   She was noted to have worsened quickly by her neurologist during her visit with him on 09/29/2022. In particular, she was noted to be forgetting  conversations, misplacing and losing things, having difficulty with cooking, having difficulty with speaking in longer sentences, having difficulty with counting/math so that her family needed to help with finances, and she was no longer able to drive safely. At this visit, her neurologist explained results from her spinal fluid that showed sings of CJD, including a positive RT-QulC, elevated total tau protein, and elevated 14-3-3 (specifically, these  tests were done by the facility, which rated the likelihood of prion disease as >98% using the combination of these spinal fluid results). An autoimmune encephalitis panel in the blood done by lab was negative. On 10/12/2022, you informed Included Health that patient had lost 20 pounds over the past 4 months, that her personality has changed (meaning much more emotional), and that she was walking slowly without falls.   Patient Included Health on 10/12/2022 that she was not taking any medications. She had reported to her primary care physician on 08/15/2022 that the donepezil (Aricept) prescribed by Dr. made her dizzy so she stopped taking it.   Patient followed Dr. recommendation, on 12/14/2022 she taked part in Hospice until she passed away.