A 62‐Year‐Old Man With Progressive Weakness, Multiple Neurologic Deficits, and Hypernatremia

Abstract

A 62-year-old Chinese man was admitted for progressive weakness, loss of weight and appetite, and multiple neurologic deficits. History of the presenting symptomThe patient had a 6-month history of unsteady gait and generalized weakness with constitutional symptoms of loss of weight and appetite. He consulted his general practitioner 2 months later. Laboratory investigations then showed normal complete blood count and liver and thyroid function tests. Magnetic resonance imaging (MRI) of the brain with contrast fluid-attenuated inversion recovery (FLAIR) sequences and diffusion-weighted imaging showed multiple nonspecific foci of an abnormal signal seen in the white matter of both cerebral hemispheres. VDRL serology was nonreactive. The only abnormal investigation was an elevated serum sodium level at 148 mmoles/liter (reference interval 135-145). He was referred to a neurologist, who made a diagnosis of multiple system atrophy based on features of cerebellar dysfunction and dysautonomia, which included orthostatic hypotension and erectile dysfunction. His serum vitamin E level was 11.3 mg/liter (reference interval 5.5-18.0). He was commenced on highdose oral vitamin E therapy as an antioxidant for multiple system atrophy. He subsequently presented to the general medicine department and was admitted for progression of symptoms. Medical historyHe had been attending long-term followup visits with his general practitioner for hyperlipidemia and type 2 diabetes mellitus for Ͼ10 years. Glycosylated hemoglobin (HbA1c) 2 months prior to admission was 11.8%. His regular medications included lovastatin, glipizide, and vitamin E tablets. He had no recent exposure to anyone with tuberculosis or history of pulmonary tuberculosis. Medications and allergiesHe did not consume any over-the-counter medications or traditional herbal preparations. He was adherent to his medications, but not to dietary control for diabetes mellitus and hyperlipidemia. Social and family historyThe patient was born in Singapore and was the fourth of 10 children. There was a family history of hypertension and hyperlipidemia, but no history of neurologic disease or malignancy. His younger sister had died of an unknown complication of systemic lupus erythematosus (SLE) 2 decades before. He was single and living with his father. He was retired and used to work as a taxi driver. He did not smoke tobacco or consume any ethanol or illicit drugs. Review of systemsThe patient experienced a week's duration of change in bowel habit in the form of intermittent constipation. There was no per rectal bleeding, blood mixed with stools, chest pain, shortness of breath, abdominal pain, chronic cough, or any change in micturition. There was no history of joint pain, oral ulcers, alopecia, photosensitivity, Raynaud's phenomenon, or fever. Physical examinationExamination upon admission revealed a thin man who weighed 45 kg. He appeared lethargic, but was alert, coherent, nontoxic, and apyrexial. He was noted to have significant postural hypotension: his supine blood press...

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