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Case 40
A 2 year-old girl is brought to the emergency department for new onset inability to walk. She is generally
healthy, but had a viral illness about 10 days prior. She was fine before bed last night, but this morning
was noted to be unsteady—tipping over when sitting and staggering when she walks like “she is drunk.”
She does not seem to be confused, but her speech is a little hard to understand. On examination she is
afebrile with normal vital signs. She is awake and interactive, with mild dysarthria. She has sustained
nystagmus on horizontal gaze bilaterally. She is unstable when sitting with some head titubation,
reaches for objects clumsily, and has a broad-based lurching gait.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?
Case 40
A 2 year-old girl is brought to the emergency department for new onset inability to walk. She is generally
healthy, but had a viral illness about 10 days prior. She was fine before bed last night, but this morning
was noted to be unsteady—tipping over when sitting and staggering when she walks like “she is drunk.”
She does not seem to be confused, but her speech is a little hard to understand. On examination she is
afebrile with normal vital signs. She is awake and interactive, with mild dysarthria. She has sustained
nystagmus on horizontal gaze bilaterally. She is unstable when sitting with some head titubation,
reaches for objects clumsily, and has a broad-based lurching gait.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?