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Acute Myelopathy in a 68-Year-Old Male

A 68-year-old right-handed male initially presented with a 3-week history of dizziness and blurred vision with unsteadiness on his feet. The dizziness was described as a sensation of the ground moving. No rotational component was described. He had no nausea, vomiting, fever, diplopia, hearing loss, headaches, or preceding viral illness. His medical history was significant for paroxysmal atrial fibrillation, hypertension, hyperlipidemia, remote L5-S1 discectomy, chronic low back pain, chronic bilateral tinnitus (presumed as resulting from occupational noise exposure), anosmia following a remote head injury, and microscopic hematuria (with a negative workup). His medications were escitalopram 20mg every night at bedtime, amiodarone 200mg once daily (OD), metoprolol, 50mg twice daily, hydrochlorothiazide 12.5 mg OD, acetylsalicylic acid 81 OD, and rabeprazole 20mg OD and acetaminophen with codeine (300mg and 30mg, respectively) as needed. He had no known drug allergies. He had a 27 pack-year smoking history. He denied any alcohol intake in the preceding 18 months. He was a retired army/corrections officer, married with three children. His family history was notable for ischemic heart disease. His general examination was normal and his neurological exam was only noteworthy for his unsteadiness. Head CT scans were negative. He was diagnosed with labyrinthitis and treated with prednisone 30 mg× 5 days and betahistine. His symptoms improved and he was discharged home after 5 days to follow-up with the departments of ear, nose, and throat, and ophthalmology. One week after discharge, he began to experience progressive, bilateral lower extremity numbness and weakness, with difficulties in ambulation requiring a walker. He had experienced urinary retention and incontinence and fecal incontinence on one occasion. He noted reduced perianal sensation. The patient was afebrile, with a blood pressure of 126/78 and a heart rate of 68 per minute. The neurological examination was normal for cranial nerves and upper extremities. However, the lower extremity examination was notable for bilateral leg spasticity right > left, mild proximal weakness (4– to 4+ /5), increased reflexes in the knees (3), sustained clonus in the right ankle, and an absent left ankle reflex. Sensory examination revealed a T10 sensory level to pin prick, absent vibration to the right tibial tuberosity, and decreased vibration at the left great toe. His gait was unsteady and he was unable to do a tandem walk. There was no finger to nose ataxia. He had decreased rectal tone and perianal sensation. Initial investigations revealed a normal hemoglobin and white blood cell count, but there was thrombocytopenia (range, 41-86). The mean corpuscular volume was 97.7 fL (normal range, 80-95). Vitamin B12 levels were 97 pmol/L (normal, >156). The erythrocyte sedimentation rate (ESR) was 33 and C-reactive protein (CRP) 24.9. His postvoid residual urine volume was 400 ml. A lumbar puncture was performed and cerebrospinal fluid (CSF) analysis revealed a normal glucose of 3mmol/L (normal, 2.2-3.9), an elevated protein of 513mg/L (normal range, 200-400) with cytology revealing eight nucleated cells and 126 red cells in tube 1, compared with four nucleated cells and no red cells in tube 4 (81% of nucleated cells were lymphocytes). CSF culture, cytology, oligoclonal bands, angiotensin-converting enzyme levels, and Venereal Disease Research Laboratory (VDRL) screens were negative. Antiphospholipid antibodies and lupus anticoagulants were negative. HIV serology, Lyme serology, VDRL, and hepatitis B and C surface antibodies were negative. Hepatitis B core antibodies were present.