Neuro Mystery | Figure 1

Neuro Mystery

53yWM with onset of detailed visual hallucinations 3 years ago, preceded by diagnosed “mid life crisis.” Shortly after hallucination onset, intermittent bilateral hand tremors began with intermittent stooped posture and shuffled gait. Psychiatrist was concerned for Lewy Body dementia. Outpatient neurology work up demonstrated normal brain MRI with and w/o contrast, negative DATscan, negative spinal tap. Patient was told “not Parkinson’s, Alzheimer’s or MS.” Hallucinations eased by stopping patients Wellbutrin. 1 year ago, patient’s right leg began to randomly give out while walking, worsened with time to affect both legs and having seizure-like episodes where his whole body tremors, patient is able to respond. Patient began using cane about 5 months ago. 2 weeks ago, patient developed such great difficulty with walking, he started using a walker at home, having several falls a day. Symptoms seem to be more prominent when patient is tired or stressed but never completely resolve. Presented to the ER 7 days ago related to rapid loss of walking ability and uncharacteristic outbursts of “rage”. Negative work up for autoimmune encephalitis. Negative EEG x 2. Normal EMG. Spinal imaging negative besides age-related degenerative lumbar changes, and some mild stenosis in the cervical spine. No abnormal copper levels. No PMH drug use. Had exposure to fertilizer known to cause Parkinson’s disease as a child growing up on a farm. Also had skull fracture from traumatic car accident at the age of 15 with no long-term neurological effects. No high-risk sexual behavior. Over the past 2 days inpatient, patients hands have started to become weaker, unable to open bottle of water or banana. Patient is a chronic migraine sufferer. His mother has Parkinson’s disease. No FH Huntington’s.

The author made 2 updates to this case

Update 1

Have ruled out neurosyphilis, HIV encephalitis. Considered neuro functional disorder, but symptoms have been insidious in onset, no sudden appearance of symptoms after traumatic event. Thank you for any help you can provide.

Update 2

Patient is now in inpatient rehab. He has had progressive worsening of his gait. He was able to walk with cane assistance 3 weeks ago. When he stands now, his legs give way. In his attempt to remain standing, or take a step, his legs violently and coarsely shake the more effort he used. When walking, during attempting to take steps, his feet involuntarily and rapidly stomp. When he extends his legs at the knees from a sitting position, his legs will involuntarily, sometimes rapidly and violently kick.