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74r male struggling with chronic visual symptoms referred as a possible ocular Myasthenia due to right eye ptosis. AchR-Ab negative and SFEMG showed no jitter/block. Further history revealed 1-2 year of visual hallucinations, 5years of insomnia with a fragmented sleep and stereotyped mumbling during sleep, 1 year of intermittent oropharyngeal dysphagia, recurrent cough, feeling of dizziness on changing position or head turning, action tremor, progressive worsening of balance with falls. Examination showed signs of cerebellar phenomenology with horizontal gaze evoked nystagmus, hypometric saccades, bilateral postural and kinetic tremor with dysmetria l>r, broad based gait with mild shuffling & impaired tandem walking, preserved VOR. He appeared fidgety and right ptosis was fixed with negative curtain sign. Patient had reduced MOCA scores. Autoimmune encephalitis panel was negative, MRI brain-hemosiderin basal ganglia deposits but preserved brain stem volume. CSF results were unremarkable including negative result for Alzheimer biomarkers. ERG confirmed macular dysfunction and visual hallucinations considered to be Charles Bonnet in aetiology. Further immunological results revealed a positive IgLON-5 Ab with titre >1:1000. IgLON-5 Ab disease is rare, has serious prognosis and an evolving phenotype but characteristic features are sleep and gait disorder, bulbar dysfunction and cognitive impairments. Optimal therapy is not clearly defines, options include steroids, IVIG and rituximab. Autopsy series has shown tau deposits in hypothalamus and brainstem tegmentum. Awaiting HLA-DRB110:01 results as studies shows condition is genetically predisposed.dhruvock27@yahoo.com