A 63-year-old woman with urinary incontinence and progressive gait disorder

CASE PRESENTATION

A patient reported fatigue and imbalance for “most of her life.” As a child, she walked more slowly than others and had difficulty ice skating. She noted definite gait impairment about 16 years before presentation and this was more noticeable to her family 13 years before presentation. Since then, she had a slowly progressive gait disorder. She started using a cane 4 years before presentation, a walker 2 years before presentation, and a scooter about 1 year ago. She developed bladder frequency and urge incontinence about 15 years before presentation, which also slowly worsened.

She reported some pain and “dead feeling” in her feet that worsened in the evening and when tired. She had never experienced attack-like worsening or resolution of her neurologic symptoms, and had no history of optic neuritis, brainstem symptoms, or memory impairment. CSF examination 13 years previously was reportedly negative for multiple sclerosis (MS) and tests for adrenomyeloneuropathy and genetic testing for inherited spastic paraparesis were reportedly negative.

Interferon β-1a IM once weekly was started 10 years previously but was discontinued after 1 year for lack of benefit and switched to glatiramer acetate, which the patient remained on for 7 months. She was then treated with mitoxantrone, which was discontinued because of echocardiogram abnormalities, which improved after its discontinuation. Over the previous 1 year, she was receiving monthly IV immunoglobulin G (IVIg) and had received scheduled IV corticosteroids monthly with mild transient symptomatic improvement lasting only 6 months.

She had dry mouth, which was attributed to medication, and occasional mild headaches, but no significant constitutional symptoms or significant travel history. She had a history of tick exposure but had negative Lyme disease testing.

She had had a hysterectomy for benign tumor with deep venous thrombosis following surgery, prior sinus and lumbar surgery, and hyperlipidemia. Her medications …