Case Presentation: A 28-year-old woman with alcohol use disorder presented with acute decline in mental status and gait instability. One week earlier she had been alert, oriented, and ambulatory with a walker; on arrival she was oriented only to self, withdrawn, and markedly unsteady. She had been hospitalized the prior month for confusion, slowed speech, ataxia, and new hyperpigmentation. Imaging and history at that time led to a diagnosis of Wernicke’s encephalopathy (WE), and she was treated with IV thiamine and folate before transitioning to oral therapy. She was also started on prednisone for newly diagnosed systemic lupus erythematosus.During the current admission, she became nonverbal but followed commands. She appeared disheveled with poor hygiene and hyperpigmentation of the axillae, neck, ankles, and feet. Her differential diagnosis included lupus cerebritis, recurrent Wernicke’s, JC virus infection, syphilis, catatonia, acute disseminated encephalomyelitis, Whipple’s disease, and Marchiafava-Bignami disease (MDB). She had a history of heavy alcohol use, rapid weight loss with phentermine, and positive ANA, anti-dsDNA, and anti-Smith antibodies. MRI revealed restricted diffusion and FLAIR hyperintensities in the corpus callosum and periventricular white matter. JC virus, glutamic acid decarboxylase antibodies, and Treponema antibody were positive. She underwent trials of high-dose steroids, IVIG, thiamine, folate, and penicillin G. She was moved to a windowed room for sensory stimulation.
Discussion: Diagnostically, this case reflected the danger of premature closure. The initial assumption of WE aligned with her social history but delayed the recognition of MBD, which classically involves lesions of the corpus callosum rather than the periventricular regions typical of Wernicke’s. The coexistence of lupus and positive JC virus testing further complicated evaluation. Her intermittent catatonic appearance raised psychiatric considerations, while infectious and inflammatory etiologies were ruled out through collaborative specialty involvement including neurology, rheumatology, psychiatry, and infectious disease.The patient had daily fluctuations in mention that did not quite fit any diagnosis. For example, after a technician washed and braided her hair, she showed unexpected lucidity. Similarly, sitting in the hallway with her daughters, listening to music, and engaging with her environment led to visible improvement in affect and responsiveness. These moments demonstrated that meaningful sensory input, human connection, and basic dignity can influence neurologic and emotional recovery, even in rare and complex conditions.
Conclusions: This case underscores the essential role of multidisciplinary collaboration in diagnosing uncommon diseases. When a presentation does not fit typical patterns, coordinated input from multiple specialties can prevent delays and improve outcomes by bringing diverse perspectives and expertise to the patient’s care. Equally important, it highlights how patient-centered care extends beyond medical treatment. Family presence, personal hygiene, natural light, music, and conversation can restore connection, identity, and engagement. In complex neurologic illnesses such as MBD, accurate diagnosis and thoughtful treatment must exist alongside compassionate caregiving to support recovery and preserve dignity.