Case History/examination:
On 22 December 2019, a 79 years-old Iranian gentleman was referred to
our hospital for diagnostic lumbar tap. He was a building painter and
had an educational level of 6 years Primary School. The symptoms were
begun since one year ago, primarily urinary incontinence and then gait
disturbance. In addition, his family members noticed gradual decline in
cognitive function, in the form of repeated questions and statements,
word finding difficulty and time and place disorientation for recent
several months. There was also some history of visual hallucination and
rapid eye movement (REM) sleep behavior disorder.
The past medical history was positive for diabetes mellitus,
hypertension and cardiac arrhythmia that underwent permanent pacemaker.
His medications included rivaroxaban, insulin, bisoprolol, valsartan,
simvastatin, clonazepam and duloxetine.
The physical examination revealed positive Myerson sign, absent ankle
reflex, stocks and gloves hypoesthesia, and mild tremor in left hand.
There was no rigidity, bradykinesia, ideomotor and ideational apraxia,
and grasp and snout reflexes. Standing posture was slightly stooped with
prominent postural instability. The walking was laborious needs help and
consisted of wide based gait, very short steps and shuffling, in favor
of frontal lobe gait. Neuropsychological assessment showed impairment in
memory, attention and visuospatial domains. The total score of
Mini-Mental Status Exam (MMSE) and of Montreal Cognitive Assessment
(MoCA) were 19 and 14 out of 30, respectively.