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Stumbling towards a diagnosis
  1. B R Wakerley1,
  2. E P Wilder-Smith1,
  3. N Yuki1,2
  1. 1Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  2. 2Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  1. Correspondence to Dr Benjamin R Wakerley, Gloucestershire Royal Hospital, Gloucester, UK; benwakerley{at}fastmail.fm

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A previously well 24-year-old man presented with 4 days of increasing gait disturbance and clumsiness with tingling sensations in his forearms. He could still walk without the help of others and manage stairs but could not run. He drank alcohol socially, although rarely got drunk. On examination, his vital signs and cognition were normal and there was no meningism. Pupils were equal and reactive to light and accommodation. Eye movements were full in all directions and there was no nystagmus. The remaining cranial nerve examination was normal. Power was full in all four limbs but deep tendon reflexes were absent. Pinprick, touch, position and vibratory sensation were normal. When sitting without arm support and eyes closed, there was mild side-to-side body sway. Finger–nose testing and heel–shin testing showed moderate dysmetria in all four limbs. His gait was broad based and severely unsteady with non-directional reeling. Tandem gait was not possible. Romberg's test was negative.

Question 1

What pathology best explains his unsteady gait?

What further information in the medical history may help clarify the underlying cause of the present illness?

Comment

Gait disturbance without weakness is due to cerebellar, vestibular or sensory afferent dysfunction. His truncal ataxia, limb dysmetria and gait unsteadiness were symmetric, which narrows localisation considerably. Cortical pathology in the absence of unilateral signs and encephalopathy is unlikely. Similarly, brainstem involvement seems less likely, given the normal cranial nerve examination. Vestibular disease is unlikely as it is usually unilateral and accompanied by nausea and vomiting. Acute onset vestibular gait abnormality is also generally incapacitating with inability to walk. Vestibular eye signs to look for (there were none) are rotational nystagmus in primary position further provoked by head movements. There were features of cerebellar disease: ataxic gait with a broad-based non-directional reeling occurs in bihemispheric and midline cerebellar disease. Although the sensory examination …

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