44-year-old single male, living with his mother and working in sheltered employment. Diagnosis of Residual Schizophrenia (F20.5, ICD-10) (11) in follow-up at his Mental Health Centre and with psychopharmacological treatment with 400 mg of amisulpi-ride, 10 mg of olanzapine and 10 mg of diazepam. Non-daily but sustained use of tramadol, cannabis, alcohol and cocaine. As somatic antecedents, he has difficulty in walking, he walks with a crutch, as a consequence of a polytraumatism after a precipitation in the context of a psychotic episode 14 years ago.
The patient was found unconscious at home by his mother, unresponsive to stimuli and unable to say for how long he had been in this state. Self-intoxication with an undetermined amount of tramadol, benzodiazepines, alcohol and cocaine. He was admitted to the Intensive Care Unit for 6 days. Complications included rhabdomyolysis, acute renal failure and pneumonic process. Normal cranial CAT scan. Stabilisation and transfer to the Internal Medicine ward, one week of admission, somatic overcoming of the episode.
Transfer to the Psychiatry Department, voluntary admission. During the first five days of admission to the Psychiatry Unit, the patient remained psychopathologically stable. No psychotic decompensation, critical of the episode which he defines as a "high" and of which he states that he cannot remember the specific conditions but he does remember a previous discussion with his mother. Adapted to the rhythms of the unit, participates in occupational therapy activities. Euthymic, within the previous defectuality, concrete plans for the future, outings with the family with adequate response, possibility of discharge and follow-up at his Mental Health Centre.
However, after these first asymptomatic days, the patient began to progressively present episodes of temporo-spatial disorientation accompanied by marked bradypsychia, ataxia (from crutch to walker) and generalised motor slowing. Mnesic failures accompanied by an effort to remember, aphasia and apraxia. However, the patient is calm and placid. No anxiety, sustained sleep. No changes in previous psychiatric treatment.
Despite the family's insistence on pointing to "a psychotic break" (...) the picture is framed within a cognitive deterioration of cortical characteristics with marked impairment of the attentional system, executive function, memory and linguistic function. The EEG showed marked lenification and diffuse attenuation of the background rhythm. After assessment by Internal Medicine and Neurology, she was transferred to the Neurology Department.
The initial cranial MRI showed a supratentorial diffuse leukodystrophy pattern, predominantly fronto-parietal, hyperintense in T2 and with a discrete component of restriction in the diffusion sequences. (MRI-T2, image 1; MRI-T2-FLAIR, image 2).

Ten days later, in comparison with the previous MRI, greater signal alteration was observed in the diffusion sequences with progression of the picture in T2 and T2-FLAIR at bilateral parieto-occipital level and regression in T2-FLAIR in frontal and temporal poles.
During the twenty days of admission to the Neurology Department, no infectious symptoms or analytical alterations were observed and serology and antibody tests were normal. It was concluded that the clinical and neuroimaging alterations were compatible with late hypoxic encephalopathy, leaving the possibility of previous leukodystrophic lesions in the white matter in doubt. However, there was no family history of interest and there was no previous history suggesting the presence of leukodystrophy. During his stay in Neurology, the patient slowly improved spontaneously, maintaining the previous psychiatric treatment. On admission he was only able to walk with a walker and needed to be guided. On discharge he is able to move around with walking sticks without difficulty, he is able to throw coins into the coffee machine, his bradypsychia and memory have improved significantly, but he still has moments of disorientation. He attends the Rehabilitation Service on a daily basis.