A 69-year-old man develops 3 years of increasingly effortful, halting speech. His sentences are short and grammatically simplified ('I go... shop... bread buy'), he misarticulates sounds inconsistently, and his comprehension of conversation remains excellent. Repetition of complex sentences is impaired, object naming on confrontation is relatively preserved, and behaviour and social conduct are normal. MRI shows left inferior frontal and insular atrophy. Which variant is this?

• A Semantic variant primary progressive aphasia
• B Logopenic variant primary progressive aphasia
• C Wernicke aphasia from a left middle cerebral artery stroke
• D Nonfluent or agrammatic variant primary progressive aphasia ✓

Explanation

Effortful agrammatic output, apraxia of speech with inconsistent sound errors, preserved single-word comprehension, and left inferior frontal plus insular atrophy define the nonfluent or agrammatic variant of primary progressive aphasia, usually a tauopathy. The semantic variant loses word meaning with fluent empty speech and anterior temporal atrophy, while the logopenic variant features word-finding pauses with spared grammar and impaired repetition out of proportion to output, typically due to Alzheimer pathology. Wernicke aphasia impairs comprehension.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.