88-Year-Old Man With Mental Status Changes and Vesicular Lesions

Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN (H.K., N.M.G.); Advisor to residents and Consultant in Primary Care Internal Medicine, Mayo Clinic, Rochester, MN (T.H.P.). A n 88-year-old man with a remote history of rectal carcinoma after abdominoperineal resection, Parkinson disease treated with carbidopa-levodopa, and a recent diagnosis of left-sided parotitis presented to his local urgent care center with a 24-hour history of vesicular lesions involving the left side of his forehead. The following day, he began to experience confusion, visual hallucinations, urinary incontinence, and unsteady gait and presented for admission to the hospital. On presentation to the emergency department, his vital signs were as follows: pulse rate, 80 beats/min; blood pressure, 134/51 mm Hg; oxygen saturation, 93% while breathing room air; respiratory rate, 18 breaths/min; and temperature, 37.0 C. He was awake and interactive and answered questions appropriately. Approximately 3 hours later on the general medicine ward, the patient appeared ill with altered mental status. He was obtunded, somnolent, minimally responsive to vigorous sternal rub, and unable to provide history. Bilateral periorbital edema and erythema alongwith vesicular and crusted lesions were noted predominantly on the left side of the forehead and scalp, with no lesions on the nose. Scattered lesions were also noted on the right side of the forehead, and crossing the midline on the trunk and back. The neck was rigid. He did not have photophobia, and his pupils were equal and reactive to light with bilateral conjunctival injection noted. No facial asymmetry was seen. Computed tomography of the head revealed moderate preseptal and periorbital soft tissue swelling, greater on the left. No acute intracranial abnormalities were seen. Initial laboratory studies revealed the following (reference ranges provided parenthetically): white blood cell count, 9.6 10/L (3.5-10.5 10/L); hemoglobin, 12.0 g/dL (13.5-17.5 g/dL); serum creatinine, 1.1 mg/dL (0.8-1.3mg/dL); alanineaminotransferase, 21 U/L (7-55 U/L); aspartate aminotransferase,