Clinical Reasoning: A 48-year-old woman with confusion, personality change, and multiple enhancing brain lesions

A 48-year-old woman was transferred to our service with confusion and a change in her personality. She had presented initially with several days of malaise, abdominal pain, and nonproductive cough. She had also experienced multiple mechanical falls at home and reported weight loss of 20 pounds over 1 month. Her examination was notable for mild epigastric tenderness without guarding, a blunted and indifferent affect, difficulty with multistep commands, and recall of 0/3 objects after 5 minutes. She was otherwise alert and oriented with normal cranial nerve, upper extremity, and lower extremity examinations. CT of the head was performed as part of her initial evaluation (figure, A–D). She had additional imaging given her cough and abdominal pain: CT of the chest demonstrated a right breast mass, and CT of the abdomen and pelvis showed peripancreatic, upper periaortic, and mesenteric masses.