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A 26-year-old woman presented after developing slurred speech and drooling overnight. She had a 6-month history of tiredness and poor concentration, and episodes of loss of consciousness accompanied by paraesthesia of her hands, feet and mouth. Occasionally, one arm would ‘hang in a strange way’.
Her mother reported a preceding personality change with angry outbursts and anxiety, although these had largely subsided after starting antidepressants. Her only past history was a severe depressive episode in her teens and a difficult and occasionally abusive family life. There was no family history of neurological disease.
On examination, she was alert and orientated. There was mild dysarthria but normal motor, sensory and coordination examination.
Question 1
What is the likely differential diagnosis?
Comment
The pattern of neurological features does not immediately suggest any single lesion and, with no objective examination findings, might easily be construed as functional or psychosomatic. The initial clinical suspicion was of a psychiatric presentation, given her personal history; however, her mood had recently being more stable and there was no obvious psychosocial precipitant for this acute presentation.
The possibilities of reflex (vasovagal) syncope or hyperventilation syndrome were suggested to account for the loss of consciousness with facial paraesthesia. Vasovagal syncope seemed unlikely with no presyncopal symptoms or triggers, such as prolonged standing, dehydration or stress. Hyperventilation syndrome was also unlikely, as forced hyperventilation did not reproduce the symptoms.
On presentation, the patient herself thought she was having a stroke. Despite the acute onset and nature of her symptoms, her age, examination findings and lack of risk factors made this unlikely. Stroke mimics can occur in young people and form part of the differential diagnoses. These include space-occupying lesions, migraine, focal seizures, multiple sclerosis and periodic paralysis.
Question 2
What would you do next?
Comment
Routine blood tests showed only mild thrombocytopenia. There was no postural …
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