The64 years old female patient presented to the emergency room with blurred
vision, impaired visual field and episodes of migraine aura like fortification
illusions, and persistent headaches with decreasing intensity over the past
days. Three years ago, patient admitted to
hospital with headache and suspected brain infarction. A cerebral CT showed a
small, wedge-shaped hypo density with superficial cortical calcifications in
the right occipital lobe. The contra lateral occipital lobe showed slight hypo
dense areas within the sub cortical white matter. The patient’s history,
additionally, included rheumatoid arthritis since 2007, which was treated with
methotrexate (MTX, 15mg weekly) subcutaneous. The patient, however, revealed,
that she was not utterly adherent to her intake of folic acid after MTX application.
Atcurrent admittance, neurological examination showed visual extinction
phenomenon to the lower left and mild optic ataxia to the left. There were no
nevi on the patient’s face or in her eyes. An intellectual disability or hemi
paresis could not be observed. Family history showed no neurological diseases. The
blood tests on admission showed low levels of folic acid (3.9μg/ml). Levels offolic acid were not measured prior to presentation at hospital. Blood samples
from the past years showed continuously increased values for Mean Corpuscular
Volume (MCV) and Mean Corpuscular Hemoglobin (MCH) up to 103fl and 35pg,
respectively. Anti-gliadin antibodies were negative. EEG showed abnormal slow
brain activity with delta waves over the right parieto-occipital lobe.
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