Alcohol is Never the Answer, but it Does Make You Forget the Question (video)

A 63-year old male presented with confusion, ataxia, nystagmus, and bilateral abnormal head impulse test in the context of alcohol abuse. A brain MRI on day of admission did not reveal any acute abnormalities. A diagnosis of Wernicke's encephalopathy was entertained. Of note, the patient's head impulse test gain did not improve after thiamine infusion. Two days later, the patient developed right inter-nuclear ophthalmoplegia, left facial palsy, and dysphagia. CSF studies revealed 52 nucleated cells, 94% lymphocytes, normal protein and glucose. Repeat MRI revealed a T2 signal hyper-intensity in the left anterior inferior lateral frontal lobe, left hippocampus, left para-hippocampal gyrus, left amygdala, bilateral thalamic pulvinar nuclei, and the medial right frontal lobe. There was also subtle inferior extension to the mesencephalon/left paramedian pons. Thiamine levels came back normal. A paraneoplastic panel showed presence of anti-Hu paraneoplastic antibodies. The patient received 5 days of high dose steroids, followed by IVIG, and was continued on 60 mg daily of prednisone. An evaluation to establish the primary neoplastic etiology was initiated.