I drank too much and now I can’t walk: a case of alcohol-ind
A 36-year-old male presented to the emergency room with a 3-week history of multiple episodes of dizziness, lightheadedness, blurry vision and tinnitus after standing up. He also reported an episode of near-syncope with trauma to the head 1 day prior to presentation.

The aforementioned presentation was his third in a period of 3 weeks. He endorsed a 40 kg unintentional weight loss in the past 2 years. He had increased sleep, muscle and bone pains, tingling and numbness of his fingers and in his lower extremities distally to his knees.

Past medical history was significant for type 2 diabetes mellitus diagnosed in January 2017 with a hemoglobin A1c (HbA1c) of 7.9% which increased to 10.5% in December 2018 few months before presentation. His diabetes mellitus was being treated with Metformin which he was not compliant with. He also had proliferative diabetic retinopathy, bilateral diabetic peripheral neuropathy treated with Gabapentin, right cerebellar gliosis 2/2 to right frontal ventriculostomy along with a history of depression and alcoholism (reports drinking 10 beers per day for 2 years. Each beer is 24 oz. He quit 3 weeks prior to presentation). He did not report any intake of antidepressant therapy or sedatives.

He is a thin, pale man of Asian descent. There were no signs of dehydration such as dry mouth, lips and eyes. Orthostatic blood pressures: 148/97 mm Hg while sitting and 93/64 mm Hg upon standing. Generally normal body and neurological exams. Neurologic exam was normal. Tilt table test was not performed because the hospital does not have the specific facility for the test. Pertinent initial laboratory findings were: HbA1c 10.2%, AST 87 mg/dL and normal ALT. An EKG showed long QT segment with QTc?=?0.53 s.

He was admitted for further work-up of dizziness. Twenty-four hour telemetry were unremarkable. No cardiac echocardiography was performed. No dehydration was suspected due to normal laboratory work-up.

During hospitalization, he was evaluated by an endocrinologist and extensive laboratory studies including PTH, 25-OH vitamin D, vitamin B12, Free T4, ACTH, Cortisol, Testosterone, LH, FSH, Prolactin and IGF-1 levels all returned normal. Serum aldosterone and renin levels were normal excluding adrenal insufficiency as a cause for orthostatic hypotension.

A CT scan of the abdomen and pelvis with IV contrast to rule out any liver injury secondary to alcohol use was normal. A CT brain without contrast showed no acute intracranial injury. A right cerebellar gliosis was evident along with prior right frontal ventriculostomy. A brain magnetic resonance imaging (MRI) showed mild gliosis in the lateral aspect of the right cerebellar hemisphere underlying a right occipital craniectomy and a mild right frontal gliosis along a prior shunt tract.

He worked regularly with physical therapy and was taught posture stabilizing exercises, which improved his functional capacity and ambulatory abilities. He was diagnosed with dysautonomia secondary to alcoholism. His blood pressure improved to 130–140/70–80 mmHg with no significant drop on lying/standing measurements. He was discharged on midodrine 10 mg thrice daily, gabapentin 300 mg thrice daily and thiamine 100 mg daily.

In a 6-month follow-up visit, his HbA1c decreased to 6.5% being on insulin therapy. He denied any further alcohol intake. Although he was compliant to his medications, and was following instructions for management of his varicose veins, he still had intermittent episodes of orthostatic hypotension with blood pressure dropping occasionally to 100/50–60 mmHg. However, he did not report any further near-syncope episode. A gastrointestinal evaluation was scheduled because of significant weight loss.

Source: https://academic.oup.com/omcr/article/2021/8/omab072/6350614
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