Case 5: 42-Year-Old Woman With Jumping Eyes, Unable to Get Up

Presenter: Majid Fotuhi, MD, PhD, Chief Resident in the Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland.Mentor: David Zee, MD, Professor of Neurology and Director of the Neurovestibular Clinic, Johns Hopkins Hospital, Baltimore, Maryland.  

March 15, 2002

In This Article

Case Presentation

A 42-year-old woman was brought to the Johns Hopkins emergency department on December 28, 2000 by her grandmother. Her chief complaint was "I hurt all over."

The patient had fallen while walking in her house 2-3 days prior to coming to the hospital, and was unable to get up. She could not contact anyone and had to lie on the floor until her grandmother came to visit her. She denied loss of consciousness, headache, chest pain, or shortness of breath. Her grandmother noted that the patient was lying in her urine, which seemed to be "bloody."

In the ED, the patient was apathetic and a poor historian. She did not appear to be too concerned with her inability to move. She remembered falling twice before and being hospitalized for a couple of weeks each time; she did not remember the exact time and the cause of her falls or the events during her hospitalizations. She appeared to confabulate, saying that once she was "running away from a snake" in her house, and another time she was "running in the rain and fell as she was jumping over a log."

She denied having any significant past medical history. She knew she was taking asthma and blood pressure medications, but did not recall their names or dosages. She told us she stopped using alcohol 7 years ago. She smoked half a pack of cigarettes per day. She denied using IV drugs. Her review of systems was notable for a 50-lb weight loss in the last 3 years due to a very poor diet. She had diarrhea for 2-3 days prior to this admission.

  • Afebrile (98.3). BP: 128/73 with a pulse of 103

  • Alert, oriented, and in no acute distress

  • Supple neck, no skin lesions, and no evidence of peripheral edema or trauma

  • Generalized grade 3/5-4/5 extremity weakness, proximal worse than distal

  • Normal reflexes and sensory exam, but unable to stand or walk

The patient was given intravenous fluids containing magnesium, thiamine, and multivitamins. She was admitted to the medicine service for further evaluation and treatment.

The patient had a history of heavy alcohol consumption, an average of 1 pint of liquor daily, since age 12 years. We calculated that she had consumed the equivalent of more than 1 ton of ethanol in the past 30 years. As a result, she had suffered from alcohol-related hepatitis, gastritis, gait ataxia, and pancreatitis. She also had a history of hepatitis A and C, hypertension, asthma, and depression.

The records indicated that she had experienced 2 severe falls, in June 2000 and in early December 2000. She required hospitalization each time. Her creatinine kinase levels were elevated, in the 10,000 -20,000 range, and she had been diagnosed with rhabdomyolysis. During her last admission, she was also noted to be demented (mini mental exam score of 20/30), with a left abducens nerve palsy. No clear diagnosis was established in either of her 2 previous hospital admissions.

According to her records, she was taking paroxetine 20 mg at bedtime and was noncompliant with her asthma and hypertension medications. Her family history was significant for lung cancer in her mother and hypertension with coronary artery disease in her father. She was on disability compensation for "memory problems," and lived alone in Baltimore. Her grandmother and teenage daughter visited her regularly.

After being treated with IV fluids for 2 days for presumed rhabdomyolysis, her weakness improved gradually. The house staff noted that she had nystagmus and decided to obtain a neurology consultation for further evaluation.

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