Clinical Reasoning: A 62-year-old woman with deafness, unilateral visual loss, and episodes of numbness

Abstract

In May 2007, a 62-year-old woman presented with two episodes of right-hand numbness. The episodes were accompanied by profound fatigue. Each event lasted 5 minutes, and both occurred within a 2-week period. She also recalled an episode of right-sided numbness 30 years previously. She had a past medical history of hypothyroidism, hypertension, hypercholesterolemia, and multiple miscarriages. About 15 years ago, she began losing hearing in her left and then right ear, and she had been completely deaf for the last 8 years. Prior testing had revealed that the patient had sensorineural hearing loss, but the etiology could not be determined. Family and social history were unremarkable. ### Questions for consideration: 1. What is the differential diagnosis for episodic neurologic abnormalities? 2. What diagnostic testing would you perform? The differential diagnosis of transient sensory dysfunction is broad and includes TIA, complicated migraine, seizure, metabolic derangement, peripheral nerve compression, compressive myelopathy, multiple sclerosis (MS), and conversion disorder.1 Particularly in patients over the age 55, transient neurologic attacks that are focal, nonfocal, or a mixture of both are associated with an increased risk of stroke. Therefore, an evaluation of our patient should include carotid ultrasound, transthoracic echocardiogram, and head CT or MRI of the brain.2 The history of multiple miscarriages raises the suspicion for antiphospholipid syndrome, which may cause a hypercoagulable state. Anticardiolipin antibodies, anti beta-2 glycoprotein antibodies, and lupus anticoagulant assays could be performed to investigate this possibility. An EEG may be considered to identify epileptiform discharges, especially given the patient’s post-event fatigue. A diagnostic evaluation for the cause of her two episodes of numbness was unrevealing. Then, in January 2008, the patient noted blurred vision in her left eye that progressed over 3 days. She denied pain on eye movements, photopsia, metamorphopsia, or other neurologic deficit. Initial eye examination showed a left relative afferent defect …