Clinical Reasoning: A Middle-aged Man With a History of Muscle Pain Presenting With Progressive Leukoencephalopathy and Subsequent Coma

A 44-year-old left-handed man was admitted in October 2016 for acute-onset tingling and weakness in the left arm, cheek, and tongue and speech difficulties. These symptoms completely disappeared 1 hour later but were followed by several hours of headache, nausea, and vomiting. The patient experienced self-limiting gastroenteritis 2 months earlier. His medical history was unremarkable except for mild muscle pain aggravated by physical activity starting 4 years earlier. He never experienced a migraine, and his family history was negative for neurologic disorders. Neurologic examination was normal. There was no joint swelling, rash, renal impairment, or ocular signs. The working diagnoses were transitory ischemic attacks and migraine with aura. Brain CT and ultrasonography of the carotid arteries were normal.

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