Forgetting Everything

By LISA SANDERS, M.D.
1. Symptoms
The flashing icon announced that an instant message had arrived. The young woman at her computer at work clicked on it eagerly. It was from her fiancé. Silly boy. She’d only left him an hour ago.
“Something’s wrong,” the message read.
“What do you mean?” she shot back.
“I can’t remember anything,” he wrote. “Like I can’t tell you what we did this weekend.”
The young woman’s heart began to race. Her fiancé had been strangely forgetful lately. She thought maybe he was just tired. He’d been having trouble sleeping for a couple months — ever since they’d moved in together. The previous weekend they went to New York to plan their wedding. He had been excited when they set up the trip, but once there he seemed unusually quiet and hesitant.
“When is our wedding date?” she quizzed. “Can you tell me that?”
“No :(”
“Call the doctor. Do it now. Tell them this is an emergency.”
Over the next half-hour the 27-year-old man put in three calls to his doctor’s office, but each time, he would forget what they told him by the time he messaged his fiancée. Separated by miles of Interstate and several suburbs, the young woman was frantic. Finally, at her insistence, the man, now terrified, asked a friend to take him to the closest hospital.
A few hours later, her cellphone rang. At last. He was being discharged, he told her. The emergency-room doctor thought his memory problems were caused by Ambien, the sleeping pill he was taking. The doctor said the symptoms would probably improve if he stopped taking the medication. Probably.
“Don’t go anywhere,” the young woman instructed. “I’ll pick you up. I’m going to take you to your doctor.” She found him wandering the street near the hospital, uncertain about why he was there and even what her name was. She hustled him into the car and drove to his doctor’s office. From there they were sent to Brigham and Women’s Hospital in Boston.
2. Investigation
Late that night, the on-call resident phoned Dr. William Abend at home to discuss the newest admission. Abend, a 61-year-old neurologist, scrolled through the patient’s electronic medical record as the resident described the case. The patient, who had no history of any previous illnesses, had come in complaining of insomnia and severe memory loss. Psych had seen him — he wasn’t mentally ill. His physical exam was normal except he didn’t know the date and couldn’t recall the events of the week or even that day. The E.R. had ordered an M.R.I.
The patient needed a spinal tap, Abend instructed, to make sure this wasn’t an infection and an EEG to see if he was having seizures. Both could affect memory — though this man’s memory loss sounded pretty profound.
The next day the patient was alert and anxious when Abend came to see him. Tall and slender with earnest blue eyes, he seemed embarrassed by all that he couldn’t remember. His fiancée had gone to get some rest, and so his mother provided details. He first complained about some memory problems a couple of months earlier. The past weekend everything got much worse. Overnight, he kept forgetting he was in the hospital and repeatedly pulled out his IV.
On exam, Abend found nothing out of the ordinary save the remarkable degree of short-term memory loss. When Abend asked the patient to remember three words — automobile, tank and jealous — the patient could repeat them but 30 seconds later he could not recall even one. “It wasn’t like — where did I put my car keys?” Abend told me later. “He really couldn’t remember anything.” The neurologist knew he had to determine what was going on quickly, before further damage was done.
Abend checked the results of the spinal tap — no signs of bacterial infection. Then he headed over to review the M.R.I. images with Dr. Geoffrey Young, the neuroradiologist. The patient’s brain, Young told him, showed no evidence of a tumor, stroke or bleeding. What the M.R.I. revealed were areas that appeared bright white in the normally uniform gray of the temporal lobe on both sides of the brain.
There were only a few diseases that would cause this kind of injury, Young told him. Viral encephalitis — an infection of the brain that can be caused by herpes simplex — was certainly the most common. Autoimmune diseases like lupus, Young continued, could also cause these kinds of abnormalities. In lupus, the body’s natural defenses mistakenly attack its own cells as if they were foreign invaders. Finally, added Young, certain cancers can do this, too — it’s usually lung cancer; usually in older smokers.
The job of a radiologist in a case like this is to identify the abnormality in the imaging and outline the possible causes. The patient’s doctor must then weigh the likelihood of each disease, based on what he knows of the patient. In this case, the young man’s symptoms had been coming on gradually over two months. Abend thought that made an infection like herpes less likely. The patient had already been started on acyclovir — the drug usually used to treat this virus, since it can be deadly when it infects the brain. They would need to do additional tests of the spinal fluid to make sure there was no evidence of this viral infection.
Lupus seemed even more unlikely to Abend. It is a chronic disease that can attack virtually any organ in the body and is generally characterized by joint pains and rashes. The patient had none of these symptoms. Still, perhaps this was the first sign of this complex disease. It would be unusual, but so was the young man’s extensive memory loss.
Although cancer was an uncommon cause of this kind of injury, it seemed to Abend the most credible in this patient. Even nonsmokers can get lung cancer. And other cancers can cause the same type of brain injury. Moreover, if these symptoms were caused by a cancer, there was a good chance that they would resolve once the cancer was treated. He ordered what is sometimes called a “whole-man body scan,” a C.T. of the chest, abdomen and pelvis. They needed to look everywhere. They didn’t have time to be wrong.
3. Resolution
Results from the tests trickled in over the next few days. He wasn’t having seizures. It wasn’t a virus. He didn’t have lupus. But by the time those test results arrived they already had an answer. The C.T. of the chest had shown a large mass — not in his lungs, but in the space between them, the area called the mediastinum. A biopsy revealed the final diagnosis — Hodgkin’s lymphoma — a cancer that attacks the immune system. He had what is called a paraneoplastic syndrome, a rare complication in which antibodies to his cancer attacked healthy cells in his brain.
The patient had surgery to reduce the size of the mass and started chemotherapy. Slowly, his memory began to improve.
But even now, almost four months later, the trip to New York remains vague, and his only memory of his week-long hospital stay is his nurse telling him he was going home. His fiancée remembers the day she realized he was getting better. It was several weeks after leaving the hospital. She reminded him that he wanted to get a haircut. He told her that he tried to go the day before but the line at the barbershop was too long.
She almost cried. “At that moment,” she told me, “I finally knew that the man I loved was still in there and that he was coming back.”