| Popis: |
Context: Ataxic syndromes in the emergency department have a vast differential diagnosis, including immune, nutritional, and other etiologies. Case report: Man, 67yo, alcoholic, but previously healthy, came to ED due to complaints of falls and progressive dysesthesia in lower limbs which started 7 days from admission. He denied other toxic exposures or infectious history, except covid-19 one month before the current symptoms. Physical examination revealed mild hoarseness, left hemipalate paresis, tactile and position sense hypoesthesia, no sensory level, absence of profound reflexes; right hypotonia, global ataxia, and he was unable to walk. Neuroaxis MRI was normal. CSF obtained at D10 had 2 lymphocytes/mm3, 96mg/dL of proteins and no other abnormalities. Hb=13g/ dL, VCM=103fL, B12=424pg/mL, LDH and homocysteine were high. Negative anti-HTLV and -transglutaminase; covid-19 rapid test was positive, but rt-PCR was negative. ENMG revealed moderate sensory-motor axonal polyneuropathy. We hypothesized that the main differential diagnoses were subacute combined degeneration of spinal cord (although high level of protein in CSF) and Miller-Fisher syndrome (although ophthalmoparesis was absent). Considering that there was no motor nor respiratory symptoms, we did not offer pulse therapy and opted for B12 vitamin replacement. The patient had a favorable response to therapies and was able to walk at two weeks of treatment. Conclusions: We did not define the etiology of this case, however, it is important to keep B12 deficiency in mind (even when it is into the lab reference range) and to pay attention to post-viral atypical manifestations, mostly in the context of the current covid-19 pandemic. |
