doc_clotaire
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A 44-year-old Irish-American woman has had arthritis for 10 years, for which she has seen many physicians. She has used many medications and devices, including copper bracelets from Mexico given to her by friends. She seeks your help because for the past several months she has had increasing pain and stiffness in her hands. Her hands now show moderate ulnar deviation of the fingers and she says her wrists and knees also hurt. She has had increasing fatigue for about 1 month, alongwith a weight loss of 1.8 to 2.2 kg (4 to 5 lb). Review of her medical records, which she has brought with her, convinces you that the initial diagnosis of rheumatoid arthritis is correct. She says, "I had several drop attacks during the past 3 months."
She characterizes these attacks as episodes of weakness and loss of feeling in her legs for several minutes. During one of these episodes, she became incontinent. She currently takes aspirin about four times a day and an occasional dose of ibuprofen. On physical examination she has facial plethora and swollen and painful metacarpophalangeal and knee joints, bilaterally. The rest of the examination is normal. Which of the following is the most likely cause of her "drop attacks?" ?
(A) Adrenal insufficiency
(B) conversion disorder
(C) Atlanto-axial instability
(D) Cardiac arrhythmia
(E) Cerebral ischemia
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| babydoc4usmle
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C looks so attractive...
what is a correct one?
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| NE
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C - RA is a risk factor for atlantoaxial instability which could have described symptomes.
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| robin082006
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(C) ---->Atlanto-axial instability
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| neuroblastoma
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YES C
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| doc_clotaire
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The correct answer is C.
This vignette is lengthy and the patient appears to have
many complex issues. Careful attention to her history however allows the diagnosis to
ascertained with near certainty. The drop attacks are characterized by incontinence with
weakness and loss of feeling in her legs. These symptoms point to a neurologic defect
that affects both the parasympathetic and motor functions of the nervous system. Atlantooccipital
joint subluxation is a common problem for patients with advanced RA, as this
patient clearly suffers from. If the cervical spine were to suffer impingement from such
subluxation, it would be expected that motor loss below the level of the impingement as
well as loss of bladder control from interruption of the parasympathetic outflow (cranial
component).
Adrenal insufficiency (choice A) is characterized by hypotension, salt wasting and
fatigue. This patient gives no history suggestive of orthostasis (position blood pressure
changes) or of a salt craving. She also fails to disclose any history, which could explain
the cause of her adrenal insufficiency. The events she describes are recent in onset
precluding long-standing adrenal insufficiency. She has taken no adrenal suppressing
medications (prednisone) and has not had a severe infection (meningococcus for
example).
Anxiety (choice B) is a DSM recognized diagnosis and requires, among other criteria,
that all organic explanations for the syncopal events have been excluded. Given the very
specific neurologic symptoms that this patient complains of, pursuing anxiety as a
diagnosis without first pursuing bona fide organic diagnoses is incorrect.
Cardiac arrhythmia (choice D) capable of “dropping someone” is almost always
ventricular tachycardia. The patient does not describe a sudden “drop attack” where she is
walking or talking one second and is then “out”. She rather describes very discrete
neurological findings of leg numbness and weakness suggesting a radicular origin to her
symptoms.
Although cerebral ischemia (choice E) manifest as transient ischemic attacks are
possible, there are at least two reasons making this diagnosis unlikely. First, the
neurological symptoms reported by the patient are bilateral and involve sensory and
motor, making bilateral carotid disease (anterior and middle cerebral artery distribution)
to the motor and sensory cortex very unlikely. Secondly, the patient has long-standing
RA making this the diagnosis of choice to exclude as an etiology.
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