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Abstract

Brain stem syndrome is a condition commonly characterized by limb weakness, ophthalmoplegia and gait disturbances. The common causes of brain stem syndrome are ischemia, neoplasia, demyelination, infective and hamartomous lesions in the brain. Imaging ideally with a MRI scan is usually diagnostic in most cases and possibly following other investigations to identify systemic abnormality or CSF changes before appropriate therapy can be introduced. A 42 year old Caucasian lady presented with non-specific symptoms like lethargy, malaise, was off food for a couple of months and had lost a considerable amount of weight (4 stones=25.4 kg). She was admitted to the hospital with nausea and vomiting for a few weeks and complained of a lump in her throat. Gastroscopy was unremarkable. She also complained of sudden onset of double vision for the last few days and examination showed vertical Nystagmus. She also complained of unusual sensation in her feet and soreness in the bottom of her feet when she stood up. There was no obvious limb ataxia, absent lower limb tendon jerks but flex or plantars and intact objective peripheral senses. Gait was unsteady while walking with eyes open but was better with eyes closed. The patient was lucid the whole time. During the course of the stay in the hospital the patient developed Oscillopsia. She underwent a MRI scan which was unremarkable. She was investigated for autoimmune cause including GQ1b for Miller Fischer syndrome and paraneoplastic screen to investigate the weight loss. Lumbar puncture which was performed which showed protein of 0.69 and rest of the values are normal. She was transferred to a tertiary neurology centre. Based on her clinical examination finding and MRI report she was diagnosed with brain stem syndrome secondary to malnutrition due to functional dyspepsia. She was seen by the dieticians and NG feed was started.

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