COW: A historical case
An Historical Case
The patient was a writer and playwright with a long medical history and died aged 65. By the age of 25, he had been married and divorced. By this time he had also contracted - and recovered from - malaria and tuberculosis and a suicide attempt!
He smoked and consumed alcohol all his life and suffered many episodes of depression. Indeed, depression and intermittent alcohol excess figure prominently throughout his life. Drinking binges were often accompanied by blackout spells, which were sometimes followed by delirium tremens. These occurred primarily from his teens until the age of 40. From then, for the last 25 years of his life, he did not use alcohol in excess and for the for the last 10 years, he abstained entirely from alcohol.
Early in his writing career, the patient noted a mild tremor which had considerably worsened by age 40 to the extent that he had difficulty controlling a pencil while writing. He was diagnosed with Parkinson?s disease and treated with vitamin injections, bromides, mephenytoin, and chloral hydrate without much benefit. His handwriting became more minute as he attempted to control his shaking hand.
At the age of 55, the patient first noted unsteadiness of gait. Shortly thereafter, he began experiencing increasing difficulty coordinating the use of his arms. It was hard for him to convey food to his mouth. Impairment in articulation soon followed, so that his speech became increasingly difficult to understand. He stopped writing plays in the last 8 years of his life and gave up handwriting altogether because "my hands would almost fly off the page".
Several neurologic examinations were carried out in the last two years of his life. His speech was poorly articulated, low pitched, and nasal; "words died in the back of his teeth." Hypotonia was noted. His head and trunk swayed even while he was seated, unless he supported himself with his arms. There were coarse tremors of wide excursion when the arms were outstretched, most marked at the shoulders. Incoordination of the arms and legs was evident. He was able to stand with difficulty in the Romberg position with variable titubation of his head. His gait was wide-based with irregular placement of his feet. His posture remained erect. The deep tendon reflexes were normal, the plantar reflexes remained flexor, and there was no recorded disturbance of sensory, autonomic, or sphincteric functions. During recurrent respiratory infections, he became delirious, with temperatures of 38.8o to 39.4oC. However, no serious prolonged confusional or psychotic episodes occurred. There was no evidence of dementia.
In the last year of his life the patient had increasing difficulty in swallowing, resulting in frequent choking on morsels of food. He became sullen and reclusive and no longer interested in what went on around him. In his last month, his condition rapidly worsened. Except for a few assisted steps once or twice a day, he was confined to bed. Three days before his death, his temperature rose to 40oC, and rales at the right posterior base were noted. Antibiotics afforded no improvement.
Some Questions on the Case
1. Was a diagnosis of Parkinson's disease warranted? 2. Which areas of the patient's brain were affected based on his signs/symptoms? 3. What brain changes result from alcohol abuse? 4. Are you interested in a pathological diagnosis?