A 30-year-old male diagnosed with schizophrenia was admitted to the hospital after overdosing on his medications. He developed confusion, ataxia, and fever. During the examination, the patient exhibited lead-pipe rigidity and increased tone in his limbs. An ECG showed sinus tachycardia, and further tests including a head CT, lumbar puncture, and septic screen were negative. What medication could potentially improve this patient’s condition?
A 30 year old man is brought to the emergency department in a comatose state. He was discovered by his roommate collapsed on the floor. The roommate reports that the man had been exhibiting strange behavior over the past 24 hours and had been quite agitated and aggressive at times. Upon examination, the man has a Glasgow Coma Scale score of 8 (E 2 V 1 M 5). He has a temperature of 39.4ºC, heart rate of 120/min, blood pressure of 178/89 mmHg, sats of 98% on room air, and respiratory rate of 20/min. His chest is clear and abdomen is soft and non-tender with present bowel sounds. He exhibits globally increased tone in all four limbs.
Reviewing his electronic medical records, the only information available is a recent admission to a psychiatric hospital where he was diagnosed with paranoid schizophrenia.
CT scan of the brain shows no abnormalities.
Lab results show:
– Hemoglobin: 15.4 g/dL
– Platelets: 232 * 10^9/L
– White blood cells: 11.5 * 10^9/L
– Sodium: 143 mmol/L
– Potassium: 4.1 mmol/L
– Urea: 8.1 mmol/L
– Creatinine: 101 µmol/L
– Bilirubin: 14 µmol/L
– ALP: 63 U/L
– ALT: 28 U/L
– Calcium: 2.64 mmol/L
– Albumin: 41 g/L
– Creatine kinase: 21,000 IU/L
– Serum glucose: 6.4 mmol/L
A lumbar puncture was performed with the following results:
– Glucose: 4.9 mmol/L
– Protein: 0.3 g/L
– Culture: no organisms found
– Opening pressure: 21 mmHg
What is the most likely diagnosis?
A 32-year-old man presents to the Emergency department after collapsing at a nightclub. His girlfriend reports that he appeared disoriented and complained of feeling overheated with difficulty swallowing before collapsing while getting water at the bar. He experienced arm and leg twitching for several seconds before regaining consciousness, but was incontinent of urine and drowsy. The patient has a recent diagnosis of schizophrenia and is taking olanzapine. He consumed seven pints of lager and snorted cocaine prior to the episode. On examination, he has a Glasgow coma scale of 8/15, dilated and reactive pupils, and marked muscle rigidity with brisk reflexes bilaterally. His blood pressure is 140/78 mmHg, pulse is 89 beats per minute and regular, and rectal temperature is 39°C. Investigations reveal elevated serum creatinine kinase and myoglobinuria. What is the most likely cause of this patient’s symptoms?
A 63-year-old man presents to neurology with a tremor affecting both arms, slow activities, and recent balance issues. He also reports urinary incontinence and erectile dysfunction. His medical history includes hypertension, myocardial infarction, and hypercholesterolaemia, and he takes ramipril, bisoprolol, aspirin, and simvastatin. On examination, he has increased tone and impaired coordination. His blood tests show a low TSH and high creatinine. What is the most likely cause of his symptoms?
A 42-year-old man was on a hiking trip in Canada. He woke up at four o’clock one morning with intense neck pain that spread down to his right shoulder and forearm. The next day, the pain extended to the back of his forearm. He felt otherwise fine. His symptoms disappeared after 24 hours. However, he noticed that he couldn’t lift his right arm properly a week later, and now he’s come to the Emergency Department. During the examination of his right arm, there was atrophy of the brachioradialis, biceps, and shoulder, as well as winging of the lateral aspect of the right scapula.
Which muscle weakness is most likely responsible for the scapular winging?
A 35-year-old woman visits the clinic with a complaint of feeling weak all over. She reports that her eyelids tend to droop towards the end of the day. During the physical examination, you observe fatigability, but there is no muscle tenderness or skin rashes. Her blood pressure is 120/80 mmHg, pulse is 80/min and regular, and her BMI is 25. What neurological condition could be associated with her symptoms?
A 30-year-old woman has been referred to the neurology clinic due to facial weakness. She has noticed over the past 2 months that her eyelids tend to droop towards the end of the day, and she experiences occasional double vision. Additionally, she has difficulty smiling as the corners of her mouth droop slightly. However, she has not experienced any limb weakness or difficulty swallowing.
Upon examination, the patient exhibits bilateral facial droop and partial ptosis. She compensates for this by tilting her head up. After attempting to keep her eyes elevated for more than 15 seconds, she experiences almost complete ptosis. Eye movements are otherwise normal, and there are no abnormalities in palatal or tongue movements. Tone, power, reflexes, and sensation are all normal in both upper and lower limbs.
What is the most appropriate initial course of action?
A 44-year-old female presents with her third episode of diplopia in two years. Her first episode occurred 3 years ago, during which she was unable to abduct her left eye and had a left partial ptosis, which resolved after 4 weeks. Her second episode occurred 6 months ago, during which she experienced mild vertical diplopia, diagnosed by her GP as a fourth nerve palsy secondary to diabetic microvascular disease, which improved after 6 weeks.
Her medical history includes insulin dependent diabetes, with moderate control HbA1c (IFCC 39 mmol/mol), autoimmune hypothyroidism, and vitiligo. She is a non-smoker. During examination today, you note a failure of vertical upgaze in her right eye and 50% failure of adduction with a 50% partial ptosis. Both pupils were equal and reactive.
Her admission blood tests were unremarkable, and an MRI head and orbits showed no orbital or intracranial pathology. What aspect of her medical history is most likely to lead to the underlying diagnosis?
A 25-year-old woman presented to the outpatient clinic with a complaint of mild exertional dyspnoea that had been ongoing for two months. She reported that her symptoms were more noticeable when she walked her dog in the evening, but not in the morning. Her husband had observed that she sometimes spoke with slurred speech after the evening walk and appeared depressed. She had a history of mild anxiety and depression that had been treated by her GP.
During the examination, the patient appeared anxious, but there was no palpable lymphadenopathy. Her heart sounds were normal, and her chest was clear on auscultation. Her abdomen was soft and non-tender with no palpable masses or organs. Cranial nerves were intact, and there were no abnormalities in tone, bulk, or power in her limbs. Her reflexes were brisk and symmetrical with bilateral flexor plantar responses.
What bedside test could be used to help confirm the diagnosis?
A 29-year-old female presents to the neurology ward with double vision and muscle weakness. She reports that the weakness is worse in the evenings and is struggling to keep her eyes open. She also experiences shortness of breath, which she attributes to a recent cold. Her medical history includes type 1 diabetes and she is a smoker of 10 cigarettes per day. On examination, she has bilateral ptosis and nasal speech, and her blood pressure is 135/85 mmHg. Cranial nerve examination reveals oculoparesis on the right lateral rectus and facial muscle weakness. Upper and lower limb examinations reveal proximal weakness and impaired sensation. Blood tests show a fasting plasma glucose of 17.5 mmol/L and positive MuSK antibodies. She is started on pyridostigmine but her breathing and forced vital capacity continue to deteriorate. What is the next step in management?