Problem solving in clinical practice: an unusual cause of multifocal brain lesions

We present an interesting neurological case reinforcing our understanding of neurological anatomy, diagnosis and management but, most importantly, of compassion and humanity. A 14-year-old left-handed young man of African heritage attended the emergency department with a 4-week history of left-sided limp and 3 days of facial asymmetry and slurring of his speech. He reported a decline in the quality of his handwriting at school during this period. He had no history of fevers, trauma, pain, headaches, vomiting, neck stiffness, visual problems, breathing or swallowing difficulties. He had a background of alopecia totalis treated with topical steroid cream. He had no other medical history, medications nor allergies. He was fully immunised and family and social histories were unremarkable with no recent travel. On examination, he demonstrated mild left-sided facial weakness sparing the forehead and slow, slurred speech. The remaining cranial nerves were normal. In his left upper limb, he had dysdiadochokinesia, marked past pointing, pronator drift and 4/5 power with normal tone and reflexes. He had a left-sided hemiplegic gait with an upgoing plantar reflex on the left and normal tone. His right upper and lower limb examinations were normal. Sensation was normal throughout. Remaining systems examinations and vital signs were normal.