The New England Journal of MedicineCase Challenge: A 79-Year-Old Man with Involuntary Movements and Unresponsiveness

A Multifaceted Diagnostic Journey from Seizure Disorder to Functional Neurologic Disorder

A 79-year-old male patient presented with a perplexing case of involuntary movements and transient unresponsiveness, leading healthcare professionals through a diagnostic labyrinth. Despite multiple evaluations and treatment adjustments, the patient’s condition remained elusive, underscoring the need for a multidisciplinary approach in managing complex neurological symptoms. What is the diagnosis?

HCN Medical Memo
This case serves as a reminder of the diagnostic challenges posed by complex neurological symptoms in elderly patients. It underscores the importance of a multidisciplinary approach, involving neurologists, primary care physicians, and imaging specialists, to arrive at an accurate diagnosis and effective treatment plan.

Key Points

• The patient experienced involuntary movements for 9 months, initially lasting 1-2 minutes but later increasing to 10 minutes per episode.
• Sodium levels were consistently low at around 129 mmol per liter, with a history of inappropriate antidiuretic hormone secretion.
• MRI and EEG showed minor abnormalities, but no definitive signs of seizure activity.
• Treatment with levetiracetam initially considered for seizure disorder was later switched to clobazam due to the nature of the movements.
• The patient was finally diagnosed with a functional neurologic disorder after a series of complex evaluations.

Perspectives
Dr. Carrie Chui, a neurologist, emphasized the importance of considering a broad differential diagnosis in cases with complex neurological symptoms. Dr. Rajiv Gupta noted that imaging studies, including CT angiography, showed no evidence of acute territorial infarction, complicating the diagnostic picture.

Additional Points

• The patient had a complex medical history, including Barrett’s esophagus, benign prostatic hypertrophy, and chronic hepatitis B among others.
• The patient’s sodium levels and lactate levels normalized during his hospital stay, but episodes of involuntary movements continued.
• The patient was discharged with a recommendation for outpatient physical therapy and use of distraction techniques.

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