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A taxing case
  1. David Bourke1,
  2. Laurie Wing2
  1. 1Neurology Department, Wellington Hospital, Wellington, New Zealand
  2. 2General Medicine and Endocrinology Departments, Bay of Plenty District Health Board, Tauranga, New Zealand
  1. Correspondence to Dr David Bourke, Neurology Department, Wellington Hospital, Private Bag 7902, Wellington South 6021, New Zealand; david.bourke{at}ccdhb.org.nz

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A 70-year-old woman presented with a 2-month history of gradually progressive unsteadiness. She started to fall a few weeks before assessment and was holding furniture to balance herself. She complained of recent memory loss and constipation. Additionally she was being investigated for ‘scarring on the lung’ found on a chest X-ray. She took no medications and drank no alcohol. She had no relevant family history. On examination, there was horizontal nystagmus and dysarthria (staccato-type). She had moderate gait and limb ataxia. Romberg's test was negative. Her ankle jerks were absent but sensation was intact to all modalities. We found pitting oedema below the knees. An MR scan of the brain was normal.

Question 1

How would you classify her type of ataxia?

Comment

The eye movements, speech and limb findings suggest cerebellar ataxia. While the ankle jerks were absent, her distal sensation and her Romberg's test were normal, making it unlikely that there was a concomitant sensory ataxia. The bilateral cranial nerve and limb findings suggest a generalised cerebellar process. The speed of progression is in the slower end of the subacute category (weeks to months).

This helps to exclude several common causes of cerebellar ataxia in older patients. Strokes tend to be of sudden onset and unilateral. Degenerative conditions tend to be slower and associated with other neurological findings on examination (eg, multiple system atrophy). Her age of onset and negative family history make a genetic cause less likely.

Her cerebellar ataxia could be classified as subacute, generalised and late-onset.

Question 2

What are the main causes of a subacute cerebellar ataxia?

Comment

There is a relatively short list of conditions that can cause subacute cerebellar ataxia (table 1).

View this table:
Table 1

Causes of subacute cerebellar ataxia

Paraneoplastic cerebellar degeneration is a possibility. This tends to progress more rapidly over weeks. Patients usually …

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