Author: Alexandra Taylor, Jonathan Cleaver, Johannes von Vopelius-Feldt / Editor: Nick Tilbury / Codes: NeuC10, NeuP6, PhP3, SLO1, SLO4 / Published: 02/07/2021

A 35-year-old male attends the ED with minor injuries with weakness and paraesthesia in his legs. Over the previous 3 days his symptoms have progressed and ascended so he cannot mobilise. He denies any fever, infective symptoms or injuries.

He lives in a caravan and appears unkempt. He is recovering from alcohol dependence and admits to having ‘experimented with various drugs’ over the last two years.

Observations are unremarkable.

Examination reveals power of 4/5 in his lower legs. Lower limb reflexes are absent, and sensation is reduced distally to vibration and proprioception. Babinski’s sign is positive bilaterally. He is markedly ataxic in both lower limbs. He has a broad-based gait and is unable to tandem walk. The neurological examination of his upper limbs, cranial nerves and cerebellum is normal. He is also found to be in urinary retention.

Blood tests show a macrocytosis with mild anaemia but normal inflammatory markers, normal liver function tests and normal B12 levels. A blood sugar is also normal.

An admission under neurology is arranged.

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