Clinical Problem Solving: A 68-Year-Old Woman With Acute Apraxic Agraphia, Constructional Apraxia, and Finger Agnosia

A 68-year-old left-handed woman with a history of hypertension presented with writing difficulties initially affecting numbers and then progressing to include letters. She described an inability to form the shape of numbers and found her hand drifting towards incorrect keys on her phone despite knowing what she wanted to select. Neurological examination revealed fluent but mildly slowed speech without paraphasic errors, intact comprehension and naming, and mild temporal disorientation, where she often stated the wrong year. Her writing was characterized by hesitation, poor spatial planning, and irregular letter and number formation. She also demonstrated constructional apraxia when attempting to draw cubes and finger agnosia. Oral calculation, bedside language functions, and reading were intact. MRI revealed multifocal enhancing lesions in the corpus callosum and left inferior frontal lobe, after which brain biopsy confirmed primary CNS lymphoma. This case illustrates how isolated disturbances of writing and praxis can arise from multifocal lesions involving visuospatial-motor integration networks.