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Título

Long-term cerebellar ataxia associated with confounding factors: a complex case for assessment and management

RESUMO

Case presentation:

Patient 77 years old, 5 months of evolution of rotational vertigo, tremors of upper limbs, loss of balance with a tendency to fall and tonic-clonic seizures. Performing treatment for gastritis (proton pump inhibitor - PPI) for a long time and heavy drinker. The patient had multidirectional nystagmus with limited gaze fixation, bilateral upper limb myoclonus. Global muscular hypotrophy with preserved strength, reflexes and sensitivity. She associated movement decomposition to the coordination exam, trunk instability, did not remain standing without bilateral support and the gait was ataxic. She was investigated for the etiology of cerebellar ataxia and tests were performed to exclude autoimmune, vascular, metabolic and paraneoplastic causes, with no changes tests performed. During the investigation, a hypothesis of autoimmune cerebellar ataxia was raised as a result of high anti GAD (406Ui/ml RV < 10) with IV immunoglobulin, but with no change in the clinical picture. In addition, she maintained a persistent condition of hypomagnesemia (serum mg 0.3), initially attributed to the refeeding syndrome, was later noticed an association between normalization of serum levels and consistent clinical improvement. Renal losses and intestinal disorders were ruled out to justify hypomagnesemia, and therefore, given the prolonged use of PPIs.

Discussion:

Cerebellar ataxia can be associated with numerous causes including metabolic, paraneoplastic, vascular and autoimmune disorders. There are descriptions in the literature not only of magnesium-related ataxia but also other neurological manifestations such as seizures and involuntary movements. Hypomagnesemia caused by chronic PPI use is also described and should be investigated when other causes for the disorder have been excluded. Anti GAD may be positive in approximately 0.4 to 1.7% of the general asymptomatic population, highlighting the need to properly interpret the results obtained.

Conclusion:

Proton pump inhibitors are widely used but they can lead to absorptive changes including for magnesium and, as a consequence, lead to significant deficit and be one of the metabolic causes of neurological symptoms, including cerebellar ataxia. Patients who present compatible conditions should be investigated for the different etiologies that may trigger the symptoms, taking into account the patient's clinical improvement to correctly determine the diagnosis.

Palavras Chave

cerebellar ataxia, hypomagnesemia, anti GAD, vertigo, coordination

Área

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