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A 67-year-old right-handed man who worked as a shipping merchant was brought to medical attention by his wife in May 2011. Although born and brought up in Scotland, he was at the time living alone in South Korea; he had last seen his family in January 2011, when he was well. His wife kept in daily contact with him, and in March 2011 she noted he was occasionally forgetful, for example, mixing up friends’ names. This progressed and by May 2011 he was losing his way home from work, prompting her to visit him. In addition to the cognitive symptoms, she noted he was eating little and had an unsteady gait. He was assessed in Seoul, where a new diagnosis of type 2 diabetes mellitus was made. He had a normal CT scan of head, and his gait was attributed to a diabetic peripheral neuropathy.
He returned to the UK and attended clinic in May 2011. He could give a reasonable history and had a mini-mental state examination score of 26/30. He had been previously well, took no medications and had no relevant family history. He was an ex-smoker of 26 pack-years and drank in moderation. Before moving to Korea he had worked in the Merchant Navy, mainly in Asia. On examination, his gait was unsteady and he had signs consistent with a peripheral neuropathy, with reduced sensation in a glove and stocking distribution, and reflexes diminished in the arms and absent in the legs. Outpatient investigations were organised, but 2 weeks later his general practitioner requested admission due to a marked deterioration.
On admission, his Addenbrooke's cognitive examination (revised) (ACE-R) was 51 (attention and orientation 7/18, memory 6/26, language 21/26, fluency 9/14 and visuospatial 8/16) with confabulation noted. The general examination was normal. The neurological examination showed an ataxic gait, …
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