|Year : 2015 | Volume
| Issue : 1 | Page : 61-63
A unique presentation of monoplegia in an adult male
Fahd A Alkhamis
Department of Neurology, King Fahd Hospital of the University, Al-Khobar, University of Dammam, Saudi Arabia
|Date of Web Publication||20-Jan-2015|
Fahd A Alkhamis
Department of Neurology, King Fahd Hospital of The University, P.O.Box 2208, Al-Khobar 31952
This is a report of a 34-year-old Saudi male who presented to the emergency department of a university hospital in the Kingdom of Saudi Arabia with a 2-day history of sudden left leg weakness and inability to walk. The history was insignificant except for the death of his brother 3 days prior to the onset. His general medical and neurological examinations, lab works, neuroimaging, and electrophysiological studies were all within normal limits. The possibility of a conversion reaction precipitated by grief was considered. Psychiatric evaluation confirmed the diagnosis of a dissociative (conversion) motor disorder. The patient made steady improvement with cognitive behavioral therapy. The possibility of psychogenic origin should be considered in patients presenting with sudden gross neurological symptoms.
هذه دراسة لمريض سعودي عمره 34 عامًا أحضر لقسم الطوارئ بمستشفى جامعي لضعف بالرجل اليسرى وصعوبة في المشي لمدة يومين. وقد تبين من التاريخ المرضي أن أخاه قد توفي قبل ثلاثة أيام من بداية الضعف. وكان الكشف ألسريري العام والعصبي بالإضافة إلى الفحوصات المخبرية والإشعاعية وتخطيط الأعصاب كلها طبيعية وبالنظر إلى احتمال حدوث الضعف نتيجة لعامل نفسي، تم استشارة الطبيب النفسي وكان رأيه مؤكدًا لهذا الاحتمال وتم تشخيص المريض كحالة هستيرية (Dissociative motor disorder) وخضع المريض للعلاج النفسي حيث كانت الاستجابة جيدة ومستمرة. وعليه ينبغي للأطباء في أقسام الطوارئ وأخصائي الأعصاب أخذ العوامل النفسية في الاعتبار في حالات أعراض الضعف العصبي الحاد.
Keywords: Conversion, disorder, dissociative, grief, monoparesis
|How to cite this article:|
Alkhamis FA. A unique presentation of monoplegia in an adult male. Saudi J Med Med Sci 2015;3:61-3
| Introduction|| |
Dissociative motor disorders (hysteria) date back more than 4000 years, to the time of Hippocrates. , It is still a transforming entity reflecting the characteristics of the patient's society and culture. Dissociative motor disorders are thought to be more common in developing countries than developed ones. ,, A recent study of dissociative motor disorders in Saudi Arabia  showed a decline in frequency compared to a study reported two decades ago. 
The present report describes an adult male who presented with a dissociative motor disorder precipitated by grief.
| Case report|| |
A 34-year-old single Saudi male who works as a cab driver led a normal life with an unremarkable past medical history. He was brought by his family to the emergency department (ED) of a university hospital with a 2-day history of sudden left lower limb weakness and inability to walk. There was no associated history of back pain, sensory or sphincter symptoms, headache, trauma or constitutional symptoms. He had 3 brothers and 5 sisters who were alive and well. However, his eldest brother with whom he lived had died suddenly 3 days prior to presentation.
The general physical examination was within normal limits with blood pressure of 122/80 mmHg. Neurologically, he was fully conscious, not particularly depressed or clearly distressed by the left leg weakness. The mental state and cranial nerves were preserved. The motor system revealed symmetrically normal muscle bulk; tone and muscle strength was grade 5 on the Medical Research Council (MRC) scale for both upper limbs and the right lower limb. The patient did not move the left lower limb voluntarily but withdrew it briskly when stimulated with a pin prick. The muscle stretch reflexes were symmetric for all limbs grade 2/4 with flexor plantar responses. The sensory system and coordination were within normal limits. His gait was abnormal, walking with the help of another, stretching and dragging the left leg on the floor.
He was initially referred to neurosurgery who requested cranial, cervical, and lumbosacral spine magnetic resonance imaging, which did not reveal any significant changes to explain his presentation. Investigations including complete blood count, liver, renal and thyroid function tests, creatine kinase, fasting plasma glucose, lipid and immune profiles, sickle cell screen, protein C, S, folate, and B12 were all within normal limits.
After referral to neurology, nerve conduction and electromyography (EMG) studies performed, showed normal motor conduction velocities for the left tibial and peroneal nerves and normal EMG.
The essentially normal results of the physical and neurological examination, and the negative neuroimaging, blood, and electrophysiological tests with the somewhat indifferent attitude of the patient suggested the possibility of a functional background for his presentation. The premise was bereavement and grief precipitated by the sudden loss of his eldest brother with whom he lived.
The patient was then evaluated by the psychiatric team. A thorough mental state examination was carried out: General appearance and behavior were normal with no abnormal movement or posture. Speech was spontaneous and coherent. Mood was appropriate, and he was not particularly depressed or elated. No delusions or perceptual disorders (hallucinations and illusions) were observed. Cognitive functions testing showed normal orientation to time, place, and person. Attention and concentration were appropriate. Recent and remote memories were intact. The intelligence was average, while the insight was absent. Supportive psychotherapy and cognitive behavioral therapy were initiated, and the patient started to improve steadily.
A final diagnosis of dissociative motor disorder most probably precipitated by a grief response to the sudden loss of his eldest brother was made.
| Discussion|| |
The psychiatric diagnosis of dissociative disorder was made along the criteria cited in the ICD-10 (Classification of Mental and Behavioral Disorders Clinical Descriptions and Diagnostic Guidelines).  The dissociated motor symptoms in a study done two decades ago in Saudi Arabia  confirmed a decreasing incidence of dissociative disorder with the increasing level of social development and sophistication in the Saudi society.  In addition, patients do not, usually, present directly from the community to the ED of a referral hospital. In the last study,  dissociative disorders were more common in females 77% and 97% of the patients were below the age of 40 years. Similar results were reported from the central region where females were 75% and 80% of the patients were below the age of 30 years.  Recent developments in the fields of neurophysiology, neuroimaging, and cognitive disorders revisited this spectrum of conversion-dissociative disorders ,,, looking for possible underlying or associated neurophysiological, neuroanatomical, or cognitive mechanisms. Dissociative disorders particularly with motor symptoms and seizures frequently present to neurology clinics and EDs. The possibility of psychogenic origin of these symptoms should be borne in mind by the neurologist.  A thorough neurological history and examination should be carried out to exclude any possibility of organic causes.
Therapy of dissociative disorder is complex and costly. , It may consist of psychotherapy and the treatment of the comorbid state, e.g., anxiety or mood symptoms. No specific pharmacotherapy is available for the treatment of dissociative disorders. To develop more specific pharmacologic treatments, more work needs to be done to elucidate the peculiar manifestations of mood symptoms in what seems to be a purely psychiatric disorder.
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