The patient was a 20-year-old male with an eight-month history of T-cell acute lymphoblastic leukemia (ALL). He presented to the emergency room with confusion and decreased level of consciousness that had worsened over the prior two weeks. He complained of generalized fatigue, weakness, intermittent nausea and vomiting and depression. His diet had consisted of only soda pop over the six weeks preceding admission.
The patient was disoriented and had a depressed level of consciousness. He appeared pale, cachectic, and had poor hygiene. Examination of the central nervous system showed lateral nystagmus and slowed motor activity in the both upper and lower extremities. Reflexes were bilaterally 2+ except at the ankles where they were 1+. Plantar responses were bilaterally downgoing.