Clinical foreign accent syndrome evolving into a multiplicity of accents

Foreign accent syndrome (FAS) is a speech disorder of abrupt onset in which the affected person's spoken output is altered such that it is perceived to have the quality of a foreign accent. FAS has most frequently been reported following stroke or trauma, but the diagnostic label has also been used to capture the clinical presentation of cases of suspected psychiatric origin. We describe here the case of a 37-year-old woman, DR, admitted to emergency for slurred speech, left-sided weakness, headache, and photosensitivity. On clinical grounds, her presentation was of sufficient concern to administer thrombolytic therapy. On day 9 of her admission DR began to speak with a French accent. Over the following months DR's speech alternated between at least five different accents, accompanied by associated behavioural changes. Neuropsychological evaluation and structural and functional magnetic resonance imaging studies conducted four months after her initial presentation revealed no evidence of disrupted language function or a likely causative lesion. This is, to our knowledge, the first description of FAS encompassing multiple distinct accents within a single individual. While the aetiology of DR's initial admission remains obscure, the course and features of her FAS over the following months are characteristic of disorders on the somatoform/factitious spectrum. This case highlights the limitations of a strict division between organic and functional disorders.

► We describe a patient administered thrombolytic therapy for weakness and slurred speech.
►  Post-acutely her speech was altered, progressing through at least five different accents.
►  Structural and functional MRI studies in this case of foreign accent syndrome (FAS) were normal.
►  This is the first description of FAS encompassing multiple distinct accents within a single individual.
► Her case highlights the limitations of a strict division between organic and functional disorders.