Clinical Reasoning: An 82-Year-Old Woman With Subacute Ophthalmoparesis and Ataxia

We present the case of an 82-year-old woman with subacute altered mental status, oculomotor disturbances, and ataxia. On examination, she exhibited bilateral ptosis, complete horizontal ophthalmoplegia, and limited vertical eye movements during upgaze associated with prominent truncal ataxia. Cerebral MRI showed a mild hyperintensity on T2 and fluid-attenuated inversion recovery sequences in the posterior brainstem extending to the upper cervical cord, without gadolinium enhancement. Clinical and radiologic features suggested an encephalomyelitis with prominent brainstem involvement. We summarize the comprehensive differential diagnosis in patients with subacute brainstem encephalitis, which includes infectious paraneoplastic syndromes and inflammatory disorders. This case highlights the relevance of performing a wide methodical screening for malignancy in case of negative initial workup.

Automated summary

We report a case of an 82-year-old woman with subacute altered mental status, oculomotor disturbances, and ataxia. The examination revealed bilateral ptosis, complete horizontal ophthalmoplegia, limited vertical eye movements during upgaze, and prominent truncal ataxia. MRI showed mild hyperintensity in the posterior brainstem extending to the upper cervical cord without gadolinium enhancement. This case highlights the importance of comprehensive differential diagnosis and screening for malignancy in patients with subacute brainstem encephalitis, in case of negative initial workup.