Case Challenge: A Woman with Ataxia and Abnormal Uterine Bleeding

Case History |
March 29, 2016

Case Challenge: A Woman with Ataxia and Abnormal Uterine Bleeding

  1. Jaime Toro, MD,
  2. David Cuellar-Giraldo, MD,
  3. Saúl Reyes, MD,
  4. Lina Quintero, MD,
  5. Nicolas Lemus, MD and
  6. Maria I. Reyes-Mantilla, MD

We present a neurological case. What's the diagnosis? How you would evaluate the patient?

  1. Jaime Toro, MD,
  2. David Cuellar-Giraldo, MD,
  3. Saúl Reyes, MD,
  4. Lina Quintero, MD,
  5. Nicolas Lemus, MD and
  6. Maria I. Reyes-Mantilla, MD

A 46-year-old, right-handed woman presented with a 7-day history of sudden onset of headache, nausea, photophobia, and phonophobia. In the last 3 days, she reported an involuntary tendency to fall to one side, difficulty walking, and slurred speech. There were no previous behavioral or mental disorders; she denied fever, alcohol abuse, and any other substance abuse or recent immunizations. Her medical history was remarkable for migraine and 2 months of abnormal uterine bleeding and pelvic pain.

The patient's general physical examination was normal. Blood pressure was 120/75 mm Hg, pulse 85 beats per minute, respiratory rate 20 breaths per minute, and temperature 36.5°C (97.7°F). Neurological examination revealed slurred speech with normal comprehension, repetition, and nomination. Some hypermetric saccades were seen (video 1, see below). Deep tendon reflexes in the lower limbs were significantly increased, and pendular reflexes were also present (video 2). The patient had bilateral abnormal heel-knee-shin (video 3) and finger-to-nose tests. Her gait was ataxic (video 4).

What is the most likely diagnosis?

  • Cerebellar ischemic stroke

  • Creutzfeldt-Jakob disease

  • Viral cerebellitis

  • Paraneoplastic cerebellar degeneration

How should this patient be further evaluated?

  • Brain magnetic resonance imaging

  • Lumbar puncture

  • Intravaginal ultrasound

  • All of the above

The second part of this three-part case has been published. Click here to read more details and questions about further evaluation.

Dr. Cuellar-Giraldo is a research fellow in the Department of Neurology, Hospital Universitario−Fundación Santa Fe de Bogotá, Colombia. Dr. Reyes is a resident in the Department of Neurology, Hospital Universitario Fundación Santa Fe de Bogotá, and Universidad El Bosque, Bogotá, Colombia. At the time of the case evaluation, Dr. Quintero was a medical student in the Department of Neurology, Hospital Universitario−Fundación Santa Fe de Bogotá, Colombia. Dr. Lemus was a medical student in the Department of Neurology, Hospital Universitario−Fundación Santa Fe de Bogotá and School of Medicine, Universidad de Los Andes, Bogotá, Colombia. Dr. Reyes-Mantilla is a resident in the Department of Neurology, Hospital Universitario−Fundación Santa Fe de Bogotá and School of Medicine, Universidad El Bosque, Bogotá, Colombia.

Editor Disclosures at Time of Publication

  • Disclosures for Jaime Toro, MD at time of publication Editorial boards Multiple Sclerosis and Related Disorders

Reader Comments (22)

Andrea Salazar Medical Student, Fundación Santa Fe de Bogota

The most likely diagnosis is Paraneoplastic cerebellar degeneration. And the diagnostic evaluation should be done with all of the above

Domenico Fusco Physician, Geriatrics

Paraneoplastic cerebellar degeneration

Shrenik Ostwal Resident, Palliative Medicine, Tata Memorial Hospital, Mumbai

cerebellar Ischemic Stroke
Ix: all of the above

Maria Damiano, MD, PhD Physician, Neurology, Paris Pitié-Salpêtrière

Paraneoplastc cerebellar degeneration associated to overy carcinoma. Anti-Yo antibody response should be positive in blood and CSF.

Lukas Sveikata Resident, Neurology, Hopital de la Tour

Paraneoplastic cerebellar degeneration
All of the above

Felix Yang Resident, Family Medicine/General Practice

Cerebellar Ischemic Stroke
D (would start with MRI first)

Anupama Gangavati MD Physician, Geriatrics, India

Paraneoplastic cerebellar degeneration

All of the above

NIDIA MONTESINO Physician, Family Medicine/General Practice, Polaris medical clinic, Belize Central America

I Suspect Para-neoplastic cerebellar degeneration, is an uncommon disorder that can be associated with any cancer; the most commonly associated are gynecologic and breast cancer , primary cancer may be located in Gynecologist area, Brain magnetic resonance imaging and Intravaginal ultrasound should be do .

DEBORAH BURKE Physician, Neurology

paraneoplastic cerebellar degeneration
ultrasound
anti-yo antibodies

mauro Physician, Neurology, uruguay

paraneoplasic cerebellum degeneration
all above

Maria Javaid, MD Physician, Endocrinology, Assistant Professor, Lahore, Pakistan

Cerebellar Stroke
Brain MRI

Lina Ariza, M.D Resident, Neurology, Colombia

- Most likely diagnosis: Paraneoplastic cerebellar degeneration.
- The diagnostic evaluation should be done with: «all of the above»

Carlos Cala Physician

Paraneoplastic cerebellar degeneration. Probable primary ovarian tumor.
Perform MRI, lumbar puncture and intravaginal ultrasound.

YiZhong Zhuang Resident, Neurology

Paraneoplastic degeneration. MRI and LP first.

Carlos Cala

Paraneoplastic cerebellar degeneration

Perform MRI, Lumbar puncture and intravaginal ultrasound.

Kyung Cho M.D. Physician, Neurology, Los Angeles,CA

Paraneoplastic cerebellar degeneration;

All of the above -.

Maria Hernandez Physician, Fundación Valle de Lili

IDx: Cerebellar ischemic stroke vs paraneoplastic cerebellar degeneration
Approach: all of the above but the puncture only after the MRI or any brain image.

Julio Acosta Medical Student, Unspecified, Hospital Universitario−Fundación Santa Fe de Bogotá and School of Medicine, Universidad de Los Andes

Paraneoplastic cerebellar degeneration

She should be evaluated with: Brain magnetic resonance imaging and Lumbar puncture ( to look for a neoplasic lesion), Intravaginal ultrasound (origin of bleeding).

Malinda Wijerathne Medical Student, Teaching Hospital Peradeniya

Due to acute onset of headache and short course of progression stroke is the most likely DD. Pelvic pain and bleeding may be due to a malignancy and it may have lead to paraneoplastic syndrome. But short duration and sudden headache can not be explained by this.
I would do all the investigation s.

ZAHRA KAHYE Medical Student, Ruzgari hospital

DDX is Cerebellar ischemic strock
And all of mentioned investigation is required

David Palmieri Fellow-In-Training, Oncology, Australia

D - all of the above

Gary Raffel Physician, Internal Medicine

Paraneoplastic cerebellar degeneration;
All of the above

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