Present Illness: A 35 year old right-handed, previously neurologically normal gentleman presented in with new onset symptoms of increasing nervousness and restlessness. He was seen by a psychiatrist, diagnosed with an anxiety disorder, and started on buspirone without any noticeable benefit. Soon thereafter, he reported akathisia along with intermittent focal dystonia of his left hand and torsional dystonia of his left upper arm for which he was treated with different combinations of benzodiazepines, diphenhydramine, and atypical antipsychotics. Five months later, he reported frequent episodes of inversion to his right foot associated with cramping and a change in his gait. He continued treatment for possible extrapyramidal symptoms and achieved limited relief with benztropine. However, by about one year after presentation, his left leg became contorted. Two months thereafter, he demonstrated generalized dystonia with prominent oromandibular features.
He continued medical treatment without success and was eventually placed in a behavioral health center after a tertiary medical facility diagnosed him with conversion disorder. By the time he was seen again by neurology, he was admitted to a psychiatry ward for uncontrolled pain from his neck torticollis along with frequent panic attacks.
During this progressive decline, he denied sensory changes, fatigability, fasciculations, muscle atrophy, visual/auditory changes, or cognitive decline.
Past Medical History: None.
Past Surgical History: None.
Allergies: No known drug allergies.
Medications: Diazepam 10 mg q.i.d.; citalopram 10 mg q.d.; zolpidem 5 mg q.h.s.; naproxen 375 mg t.i.d.
Social History: He denies tobacco, alcohol, and illicit drug abuse. He is married with two healthy children, a daughter (age six) and a son (age two).
Family History: The patient is the oldest child with three younger brothers and an adopted younger sister. They are all products of non-consanguineous Filipino parents and are all healthy. His mother is from the Panay Islands, Philippines. He denies any known family history of neurological problems.
Vital Signs: Temperature 98.0 F, Blood Pressure 124/79, Heart Rate 102, Respiratory Weight 18, Weight 125 lbs.
General: Awake, cachectic, and appears to be in moderate distress
HEENT: Normocephalic. Atraumatic. Neck was supple. No audible bruits or lymphadenopathy.
Cardiovascular: Tachycardic. Regular rhythm without any murmurs and with normal S1 and S2 sounds.
Chest: Clear to auscultations bilaterally. No accessory muscle use.
Abdomen: Thin, soft, and non-tender. Normal bowel sounds. No organomegaly.
Extremities: No edema, cyanosis, or clubbing. Distal pulses were palpable.
Mental Status: Alert and oriented to person, place, and time. He follows multi-step commands. Good fund of knowledge. Spastic speech with decreased verbal fluency. Intact repetition and comprehension.
Cranial Nerves: Retracted eyelids. Pupils were equal and symmetrically reactive to light and accommodations. Fundoscopic examination showed normal discs bilaterally. Visual fields were full bilaterally. Extraocular movements were normal. Facial sensation was intact. Positive dystonic grimacing and darting tongue protrusions to the left, averaging every 3-5 seconds. Tongue bulk and strength were normal. There were no tongue fasciculation. Bilateral sternocleidomastoid and trapezius strengths were normal.
Motor: Frequent episodes of back arching and torsion to the right. Increased tone in all four extremities with cog-wheeling in right arm more than the left. Both feet were contracted with plantar flexion and inversion along with toe flexion. Bilateral wrists and fingers were flexed. No fasciculations or myotonia.
Strength | Right | Left |
|---|---|---|
Upper Extremities | ||
| Deltoids | 5 | 5 |
| Biceps | 5 | 5 |
| Triceps | 5 | 5 |
| Wrist Extensors | 4 | 4 |
| Wrist Flexors | 3 | 3 |
Lower Extremities | ||
| Iliopsoas | 5 | 5 |
| Hip Extension | 5 | 5 |
| Knee Extensors | 5 | 5 |
| Knee Flexors | 5 | 5 |
Sensation: The patient endorsed symmetrical sensation to light touch, temperature, pin prick, and vibration.
Reflexes: 3+ bilateral biceps. 2+ bilateral brachioradialis. 3+ bilateral patellar. 1+ bilateral achilles. The plantar responses were down-going bilaterally.
Coordination: Accurate bilateral finger-to-nose, albeit slow. Unable to assess heel-to-shin. Positive dysdiadochokinesia on rapidly alternating movement testing.
Gait: Unable to stand.