Clinical Reasoning: A 50-year-old man with headache and cognitive decline

Abstract

A 50-year-old man presented with headache and cognitive decline 10 weeks after undergoing matched-donor peripheral blood stem cell transplantation for treatment of mixed-phenotype acute leukemia. His pretransplant treatment included systemic chemotherapy (cyclophosphamide, daunorubicin, vincristine, prednisone, l-asparaginase, dasatinib, and cytarabine), intrathecal chemotherapy (methotrexate), and total body irradiation. His posttransplant course had been complicated by cutaneous graft-vs-host disease. Over 1 month, he developed holocephalic, throbbing, temporal headache worse when standing and reported feeling confused. His family members reported progressively withdrawn affect, depressed mood, and decreased spontaneous activity. Before his illness, he worked in a cognitively demanding profession with no history of cognitive deficit.