Neurologic Differential Diagnosis for Physical Therapy

Journal of Neurologic Physical Therapy,  Dec 2004  by Sullivan, Katherine J,  Hershberg, Julie,  Howard, Robbin,  Fisher, Beth E

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The head CT identified no change from the patient's baseline imaging. The dilantin screen, however, revealed a toxic level of 50.5 mcg/mL. The therapeutic level of dilantin ranges from 10-20 mcg/mL with anything greater than 20 mcg/mL considered toxic/' The most frequent clinical findings associated with dilantin toxicity are nystagmus, ataxia, and lethargy/' " JG demonstrated these signs over the course of his decline.

Discussion

JG's decline in medical and functional status was attributed to dilantin toxicity. Over the course of the following week,JG's dilantin level decreased to the therapeutic level. In addition to improved functional mobility, he was no longer agitated or combative and was discharged to home from the rehabilitation hospital 10 days later.

In retrospect, the agitation and combative behavior reported by the wife in the acute hospital and observed by the interdisciplinary team in the rehabilitation setting were possible early indicators of toxicity. Additionally, ataxia is not usually associated with ICH to parietal-temporal areas. However, the patient's case was complicated by difficulty with communication (secondary to global aphasia) and the concurrence of his agitation/combative behavior with his family's absence.

Case #2 Description

RP, a 50-year-old male with a recent onset of neurosyphilis, was transferred to a rehabilitation center due to deconditioning, weakness, and functional decline after a month long hospitalization .Two months prior to his acute hospital admission, RP began to experience difficulty walking and progressive weakness and numbness in his legs. One week prior to admission he had several falls because of his instability while walking. During his stay in the hospital, RP underwent multiple tests including laboratory studies, a lumbar puncture, an clectromyography/nerve conduction study (EMG/NCS), and brain magnetic resonance imaging (MRI), which resulted in the diagnosis of neurosyphilis.

Examination

On the day of transfer to the rehabilitation hospital, RP's initial physical therapy examination was consistent with the clinical picture of tabes dorsalis, a type of neurosyphyilis, with absent proprioception, impaired sensation, and diminished reflexes distally in bilateral lower extremities." However, he also had weakness in all 4 limbs that exceeded what might be anticipated from deconditioning. This finding was discussed with the physician, who agreed that this did not fit the clinical picture of neurosyphilis. However, it was possible to rule out alternative diagnoses that could account for the weakness such as paraneoplasm, multiple sclerosis, polyneuropathy, and toxicity, based on the results of the extensive testing that had previously been done.'^'" A possible variant of neurosyphilis was considered and further diagnostic work-up commenced."'

Re examination

While RP again underwent multiple tests, he began his rehab program consisting of functional training and therapeutic exercise during physical therapy. One week into his stay, he began to complain of fatigue, nausea, nasal congestion, and headache. In addition, he had difficulty swallowing, problems with urinary output, and early satiety. These symptoms were again discussed with the physician. Because of RP's multiple symptoms and change in status, the physician ordered a repeat brain MRI. The findings of this MRI were consistent with a diagnosis of multiple sclerosis (MS)/" RP was given the working diagnosis of possible MS and the recent changes in his status were attributed to an acute exacerbation. He immediately began treatment with high-dose intravenous steroids^ and started therapy for MS with Avonex.^" RP's symptoms improved during the first day of treatment, but were then followed by further functional decline over 3 days. He changed from requiring minimal assistance to get out of bed to needing nearly total assistance. In addition, he needed help to sit at the side of his bed and was unable to walk after previously being able to sit independently and ambulate with minimal assistance approximately 10 to 20 ft with a walker. RP's main complaint was that he "felt much weaker."