The case of the lawyer's lugubrious language: dysarthria plus primary progressive aphasia or dysarthria plus dementia?

A productive, intelligent, 60-year-old practicing attorney slowly begins to notice that the language that he has commanded throughout his life is beginning to become more difficult to produce, exacting its toll on his mental energy and emotional stability. His search for answers to his diminished "memory for words" leads him through the fetid ranks of traditional medicine and into the search for a differential diagnosis involving clinical neurology, neuropsychology, and speech-language pathology. Consistencies and conflicts in the signs and symptoms between the competing diagnoses raise theoretical and clinical classification issues. A course of treatment for aphasia provides evidence to support the diagnosis of primary progressive aphasia, but the development of concommitant spastic dysarthria and dysphagia challenge current wisdom about the underlying neuropathology of aphasia and support a diagnosis of early dementia. A selective but steady and rapid decline of abilities over the course of 2 years leads to the patient's death and autopsy, from which a neuropathologic analysis was to provide the "final" and "ultimate" diagnosis. But it doesn't!