A 49-Year-Old Man With Forgetfulness and Gait Impairment

Sumaira Nabi, MBBS, FCPS; Sadaf Fayyaz, MBBS; Shahzad Ahmed, MBBS


June 27, 2017

Physical Examination and Workup

Upon clinical examination, the patient is agitated and restless, with generalized myoclonic jerks. His vital signs include an oral temperature of 98.6°F, a regular pulse of 70 beats/min, and a blood pressure of 120/70 mm Hg. His respiratory rate is 14 breaths/min.

Upon neurologic examination, the patient is conscious but confused and disoriented to time, place, and person. His speech is limited to brief, incoherent sentences, and he has dysarthria. He scores 14 out of 30 on the Mini-Mental State Examination.

The patient has bilateral jerky horizontal nystagmus; however, his cranial nerves are unremarkable. Limb ataxia with titubation is noted. His gait is broad-based and clumsy, with a tendency to fall. Spasticity is noted, along with hyperreflexia and extensor plantar responses. His abdomen is soft and nontender. No organomegaly or ascites is noted. His bowel sounds are audible. The patient's precordial examination reveals normal heart sounds. Auscultation of the lung fields reveals normal vesicular breathing.

The laboratory analysis demonstrates a complete blood cell count and erythrocyte sedimentation rate within the reference range. His liver function test results, renal function test results, serum glucose levels, urinalysis findings, ECG findings, and chest radiography findings are unremarkable. Kayser-Fleischer rings are not visualized on slit-lamp examination. HIV serology is negative.

Examination of the cerebrospinal fluid (CSF) shows normal protein, glucose, and cell count, and CSF oligoclonal bands are negative. EEG shows diffuse low voltage with slowing. Polyspikes are also noted. MRI of the brain with contrast and diffusion-weighted (DW) imaging are performed, revealing gross cerebral atrophy with asymmetric areas of diffusion restriction in the cerebral cortex (ribbon-like appearance) and left basal ganglia (Figures 1 and 2).

Figure 1.

Figure 2.


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