CASE
A 27-year-old male with a 2-week history of nausea, vomiting, failure to thrive, dehydration, and inability to eat, drink, or take medications was transferred from a rural community hospital to a tertiary center emergency department (ED). He had a history significant for schizoaffective disorder and seizure disorder but no history of alcohol abuse. His family reported that he had been to the ED twice for similar symptoms—where an infection was diagnosed and treated with antibiotics—before being sent to the tertiary care center. The patient was unable to communicate or provide a reasonable history.
Physical examination revealed a drowsy but arousable male with no obvious neglect behavior, hallucinations, or complex partial seizures. Although his vital signs were normal, he could verbalize only monosyllables and followed commands very inconsistently. Cranial nerve examination revealed bilateral impaired abduction of both eyes without nystagmus. Pupils were equally round and reactive to light. Bilateral corneal reflexes were present, and Kayser-Fleischer rings were absent. The remaining cranial nerves were not examinable. Motor findings were negative for tone without abnormal involuntary movements. Plantar reflexes were silent, and the patient had an unsteady and ataxic gait. On cognitive examination, registration was 0/3 with 0/3 recall with spontaneous and provoked confabulations. Initially, the patient was alert and oriented only to self. CT of the head without contrast (not pictured) and MRI of the brain (Figure 1) were ordered in the ED, and the patient was hospitalized on the intensive care unit for a diagnostic workup and treatment. What do the images reveal?