case_images: PMC6437310_01
case_images: PMC6437310_02
case_images: Hyperpigmentation and skinny figure due to Addison's disease.
case_images: fimmu-10-00412-g0001.jpg
case_images: PMC6437310_02_fimmu-10-00412-g0001.jpg
case_images: F1
case_images: Five years ago, she noticed hyperpigmentation (Figure 1).
case_images: Cerebral magnetic resonance imaging (MRI) findings during the stay in the intensive care unit because of stroke like episodes. The MRI showed a subacute left parieto-occipital cortical/subcortical lesion involving the precentral gyrus with T2-weighted FLAIR signal increase and diffusion restriction without respecting vascular territories and the multiple right-hemispheric chronic posttraumatic lesions. The former subdural hemorrhage showed complete resolution. In the lesion, an increased lactate peak was registered (uncorrected data).
case_images: fimmu-10-00412-g0002.jpg
case_images: PMC6437310_02_fimmu-10-00412-g0002.jpg
case_images: F2
case_images: There was a clear lactate peak in the lesion (Figure 2). The EEG showed an intermittent slowing temporoparietal on both sides (stronger on the left) and singular spike-wave complexes temporal (once temporoparietal) on the left.
case_images: Neuropsychological findings showed significant impairments in divided attention for visual and auditory stimuli combined. The recorded intelligence level was in the lower normal range (IQ = 86), which appeared discrepant with the patient's educational background (this may also be attributed to fluctuations in attention). A detailed description of all test results can be found in Table 2 in the bottom column on neuropsychological test results.
case_images: fimmu-10-00412-g0003.jpg
case_images: PMC6437310_02_fimmu-10-00412-g0003.jpg
case_images: F3
case_images: Cognitive performance showed partially below-average results (Figure 3).
case_images: Magnetic resonance imaging findings a half year after the stroke-like episodes showed a chronic cortical to subcortical parieto-occipital brain lesion on the left side involving the posterior margin of the precentral gyrus with signs of chronic hemorrhagic transformation.
case_images: fimmu-10-00412-g0004.jpg
case_images: PMC6437310_02_fimmu-10-00412-g0004.jpg
case_images: F4
case_images: The follow-up cMRI 6 months after the stroke like events showed a chronic cortical to subcortical parieto-occipital brain lesion on the left side involving the posterior margin of the precentral gyrus with signs of chronic hemorrhagic transformation and the known multiple post-traumatic right hemispheric lesions (Figure 4).
case_images: Single-voxel magnetic resonance spectroscopy imaging. Presented is a MEGA-sLASER difference spectrum from the orbitofrontal cortex (OFC) of the patient, with indicated lactate (Lac)+ resonance. In the OFC, a Lac+/Creatine concentration ratio of 0.182 was found compared to a control group (N=6; 5 males and 1 female; 28 +- 2 years) with 0.159 +- 0.01.
case_images: fimmu-10-00412-g0005.jpg
case_images: PMC6437310_02_fimmu-10-00412-g0005.jpg
case_images: F5
case_images: Single-voxel magnetic resonance spectroscopy results show slightly increased lactate (Lac)+/creatine ratios in the dorsal anterior cingulate cortex (dACC), dorsolateral prefrontal cortex (DLPFC), and orbitofrontal cortex (OFC; Figure 5).