Transient Leg Weakness in a Man from Rural Colombia

A 31-year-old Colombian man with no past medical history presents to a hospital in New York City after several minutes of sudden left leg weakness and numbness. His symptoms resolve just before arrival. During the prior 2 weeks, he also had two brief episodes of left facial twitching lasting about 10 seconds each, both of which resolved spontaneously.

He was born and raised in a rural area of Colombia and moved to New York 5 years ago. In Colombia, his family kept free-roaming pigs near the home and the house lacked indoor sanitation. He has not returned to Colombia since immigrating and denies recent sick contacts, trauma, or substance use.

Vital signs are normal. Cranial nerves are intact. Motor strength, sensation, deep tendon reflexes, and gait are all normal on examination after symptom resolution. The remainder of the exam is unremarkable.

Laboratory studies show a white blood cell count of 6.8 x 10^9/L, hemoglobin 14.1 g/dL, platelets 248 x 10^9/L, sodium 138 mmol/L, creatinine 0.9 mg/dL, and glucose 96 mg/dL. Liver enzymes are normal. Noncontrast head CT shows multiple small parenchymal calcifications. HIV fourth-generation testing is pending. CT angiography demonstrates patent cerebral arteries. Brain MRI reveals dilatation of the suprasellar and Sylvian cisterns with septated fluid-filled subarachnoid cystic lesions surrounding the proximal middle cerebral arteries, peripheral enhancement after gadolinium, and an old lacunar infarct adjacent to one of the cysts.