I can’t see, can’t move…but I’m SO healthy?

Author: Siena Imogen Hayes / Editor: Steve Corry-Bass / Codes: NeuC12, NeuC7, NeuP5, NeuP6, NeuP7, NeuP8, SLO1 / Published: 13/01/2022

A 45-year-old male presents to the ED with a 3-day history of progressive weakness in his right upper and lower limbs. On examination there was observed ataxia and ocular involvement, which only had developed within the last 24 hours on questioning.

This gentleman initially noticed progressive weakness in his right legs and arm over 3 days. On arrival he complains of ataxia due to difficulty coordinating his walking and consequently seen in a wheelchair.

He reports painful eye movement particularly during lateral gaze, but no acuity changes. On further questioning he has normal sensation in all limbs, with no LOC or seizures. He reports no trauma or sudden onset headaches.

He mentioned a similar episode of reduced mobility due to right leg weakness; 18 months prior. This resolved within 48 hours, hence did not seek medical attention.

There was an unremarkable family and social history. Three days prior he was running 20km and now currently bed bound; so deeply concerned.

On Inspection:

He is bedbound, with no obvious fasciculation, nor abnormal posturing.

On assessing his cranial nerves:

Painful eye movement particularly in the lateral gaze. He has red desaturation on testing with a red hat pin. With a torch light there is no observed response in the right eye, however an appropriate response in the left eye on testing- Relative Afferent Pupillary Defect (RAPD).

During neurological examination, there are no abnormal findings on the left side. However, both the right upper and lower limb demonstrate hypertonia, with reduced power of 3/5, with associated brink reflexes and lack of coordination. There are no changes in sensations across all modalities tested.