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A Medical Mystery: Dizziness, Gait Disturbance, and Ataxia

What’s the diagnosis?

A 39-year-old woman was admitted to the hospital because of a 2-month history of dizziness, gait disturbance, and left-sided ataxia. There was a past history of hypertension, dyslipidemia, and gastroesophageal reflux. The general physical examination was normal, with a temperature of 37°C, pulse of 84 bpm, and blood pressure of 159/90 mm Hg. Neurologic exam showed a patient who was hypoprosexic and bradylalic and had short-term memory deficit, dyscalculia, and difficulty in obeying complex commands. The pupil reflexes were symmetric, but the right pupil was larger than the left, with right reactive mydriasis. No ptosis or diplopia was found. The remaining cranial nerve responses were normal. Strength in the upper left extremity was graded 4/5, and tone was increased in the arms and legs; the remaining motor exam findings were unremarkable. Both arms demonstrated moderate ataxia, and her gait was unstable. Brain MRI findings were normal (Fig. 1 and Fig. 2). An initial EEG showed diffuse bilateral slowness (Fig. 3). A lumbar puncture revealed an opening pressure of 19 cm H₂O, with CSF glucose level of 64.9 mg/dL, and protein level of 23.2 mg/dL. There were no cells in the CSF.

Submit your proposed diagnosis to jwneuro@mms.orgjwneuro@mms.org. The answer will appear in next week’s electronic issue.

— Jaime Toro, MD, Natalia Schroeder, MD, Maria Juliana Borja, and Adriana Díaz del Castillo.

Dr. Toro is a member of the Journal Watch Neurology Advisory Board. Dr. Schroeder is a Fourth Year Resident, Programme of Neurology, Fundación Santa Fe de Bogotá, Universidad del Bosque, Colombia. Ms. Borja is a Research Assistant, Fundación Santa Fe de Bogotá. Ms. Díaz del Castillo is a Research Assistant, Fundación Santa Fe de Bogotá.

[The final diagnosis and discussion appear in the September 18, 2007 update.]

Published in Journal Watch Neurology September 11, 2007

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