A man in his forties was admitted with confusion, headache and diabetic ketoacidosis. He had a long history of type 1 diabetes mellitus and hypertension. His neighbours had found him pacing up and down, and not speaking. They said he had not been himself for the last few weeks. He had been complaining of headache. Over the previous 36 h he had developed word-finding difficulties. He was taking porcine insulin, aspirin and antihypertensive drugs. He did not smoke but he drank occasional alcohol.
Seven years previously he had had an episode of ataxia, dysarthria and polyarthropathy for 4 months. Brain magnetic resonance imaging (MRI) was normal but cerebrospinal fluid (CSF) examination showed a raised protein (155 mg/ 100 mL) and 86/cumm white cells (100% lymphocytes). He recovered without treatment.
EXAMINATION AND INVESTIGATIONS
His temperature was 39.2° C. He had a mixed expressive and receptive dysphasia, mild right facial
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