A 69-year-old woman with a “sweet” cause of instability

Abstract

A 69-year-old woman presented to the emergency department with dizziness and instability. She had a history of peripheral vertigo, tinnitus, and one episode of orthostatic syncope in recent years; her only daily medication was zolpidem. Her past medical history was unremarkable. She was cooking at home when she noticed sudden-onset dizziness with a sensation of impending fainting while standing. Dizziness was described as intense, without "room spinning," and was accompanied by unstable gait. She described the event as different from her prior episodes of vertigo. She went to bed without improvement; dizziness persisted in recumbent position.After calling emergency services, she was examined at home by a doctor who found her with skin pallor, garbled and slow speech, and bradypsychia. Blood pressure and capillary glucose levels were normal.The patient was referred to the hospital, where she was still dizzy. She was afebrile, alert, and disoriented to date, with scanning speech and very slow responses to the examiner's orders. Gait examination showed marked instability with a broad-based gait. Pupillary size was normal. There was a grade 1 bilateral gaze-evoked nystagmus. Strength was normal in all extremities, and Babinski sign was absent. There was no limb ataxia, meningeal signs, or any other abnormalities on neurologic and general examination. Recumbent blood pressure was 112/67 mm Hg and did not significantly change after 3 minutes of standing.Blood chemistry abnormalities were ruled out first. All of the following were normal in serum: urea, ammonium, creatinine, liver enzymes, lipid profile, protein electrophoresis, sodium, potassium, calcium, syphilis serology, erythrocyte sedimentation rate, and C-reactive protein.Considering the sudden onset and duration of the symptomatology with dysarthria, dizziness, and instability, an acute stroke in the vertebrobasilar territory was initially suspected, and the patient was placed on aspirin therapy. Cranial MRI was then performed and revealed no evidence of acute ischemic lesions. Magnetic resonance angiography showed only slight Practical ImplicationsConsider inadvertent cannabis consumption in elderly patients with neurologic and psychiatric disturbances of unclear origin.