Soniya Tambe*

Consultant Neurologist, Kauvery Hospital, Electronic City, Bengaluru

*Correspondence: [email protected]

Background

Gait imbalance and falls are common in elderly persons and have devastating consequences, with substantial morbidity and mortality. Maintaining postural control requires a complex integration of sensory inputs, central processing, motor coordination and musculoskeletal function to perceive environmental stimuli, and respond accordingly to control body movement.

Imbalance can be due to problems in motor coordination, sensory input and musculoskeletal biomechanics. Problems in motor coordination arise due to pathology in pyramidal, extrapyramidal, cerebellar and vestibular systems. Sensory input pathologies lie in defects in visual, sensory and vestibular perception. Musculoskeletal biomechanic failure occurs due to muscle weakness, joint pathology and instability. Each cause has a different line of management. Hence early detection of problems in balance can prevent long-term morbidity.

Here we describe a case of Sensory ataxia in a senior citizen, successfully treated with Rituximab.

Case Presentation

A 65-years -aged gentleman, with no significant comorbidities, presented to neurology OPD with history of imbalance and fear of fall, of six months duration. Problems increased gradually; he developed significant disability and required support of a person to walk ten meters. He added that problems increased in the dark; he had significant swaying of body on closing eyes, termed Washbasin sign.

On Examination

His higher mental functions were normal, and cranial nerve examination was normal, Motor examination showed hypotonia and weakness of dorsiflexion of feet, bilaterally. Reflexes were absent. Sensory evaluation showed impaired joint mobility perception in toes; vibration sense was absent till mid sheen. Gait was lordotic and high stepped and the patient preferred to look at ground while walking. Romberg’s sign was positive. Clinical diagnosis of Sensory Ataxia was made.

On Evaluation

Neuroimaging and brain and Spine were normal. Nerve conduction studies showed mild Sensory- Motor Axonal Neuropathy in lower limb. Extensive lab studies with hematological evaluation, Renal function tests, Sugar tests, Liver function tests, Autoimmune panel, Paraneoplastic panel and Protein electrophoresis for paraproteinemia was done and was found to be normal. CSF analysis showed albumin- cytological dissociation suggestive of intrathecal antibody production. Chronic Immune Sensory Polyneuropathy was considered in which nerve conduction studies can be normal due to preganglionic involvement of sensory roots.

Treatment and Response

He was treated with high dose methyl prednisolone infusion with partial response in the form of improved gait and ability to walk long distance without support. However, he developed hyperglycemia, which was not acceptable to patients’ family. Hence steroid sparing agent Rituximab was considered. He received Induction dose of Rituximab infusion and, at 2 weeks follow up, showed significant improvement in symptoms and was able to climb up and down stairs without support.

Plan is to continue maintenance schedule of Rituximab with periodic evaluation of hematological parameters and development of malignancies.

Discussion

Imbalance in elderly needs a detailed evaluation to arrive at right diagnosis so as to initiate disease modifying therapy. CISP is a relatively rare variant of Chronic immune polyradiculoneuropathy. Here we report case of CISP, successfully treated with induction of Injection Rituximab. His further course of illness needs to be followed up.

tambe

Dr. Soniya Tambe

Consultant Neurologist

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