The Eyes Have It

A CLINICAL PROBLEM-SOLVING article by Miten Vasa, from University of California, Irvine.
A 69-year-old man presented to the emergency room 2 hours after he awakened with slurred speech. The patient reported a single episode of sharp, self-limited, periumbilical pain after dinner the previous night, and he had awoken that morning with slurred speech, difficulty chewing, blurry vision in both eyes, generalized weakness, and unsteady gait. He reported drinking one pint of vodka daily, smoking one pack of cigarettes daily for the past 30 years, and smoking “crack” cocaine three times a week, most recently about 24 hours before presentation. On physical examination, the patient appeared in no acute distress. The blood pressure 203/93 mm Hg. Speech was decreased in volume, dysarthric, and almost unintelligible. The dysarthria was most pronounced when he was asked to repeat guttural sounds. There was bilateral rotary nystagmus. Because he reported difficulty chewing, a swallow evaluation was performed later that evening, during which he was unable to transfer soft food from his oropharynx. On the second hospital day, his pupils reacted sluggishly to light and nystagmus was no longer present.
In the early afternoon, before a scheduled MRI and MRA evaluation of the head and neck, the patient was unresponsive, with his eyes closed. He was no longer breathing spontaneously and was intubated. [Original Article]

「神は細部に宿る。"Der liebe Gott steckt in Detail."」の格言に違わず、眼は多くを語る。メンタリズムで有名になった神経言語学プログラミングの分野でも重要視されている。
本症例では、食餌性ボツリヌス症の症状で有名な"Dozen D's"（Dry mouth, Diplopia, Dilated pupils, Droopy eyelids, Droopy face, Diminished gag reflex, Dysphagia, Dysarthria, Dysphonia, Difficulty in lifting head, Descending paralysis, Dyspnea from diaphragmatic paralysis)の１２項目のうち３項目が眼に関する所見で、いずれも感度が上位に位置していることが眼目。

Reference

• "Descending Paralysis Ascending the Path to Diagnosis" Case Studies in Toxicology