A patient's journey: finding keys to a locked in state

December 7
He fell down from his bed today. Was it that his power was returning?

He had developed a slowly progressive weakness beginning from his left arm and spreading to involve his right arm and subsequently right leg and left leg. They also noticed tremors that were coarse and static but fast and also involved his head that went side to side in a 'no' fashion.

That was two years back, much before he fell from his bed today, much before the day two weeks back when he suddenly developed a complete paralysis of all his muscles to the extent that he could not lift a finger or utter a word although he could see and hear the world (which they/we didn't realize initially).

He could however move his eyelids and this was what brought his diagnosis to our notice.

He had locked in syndrome a recognized entity that has been much discussed before.
See:
a) http://www.bmj.com/cgi/content/full/330/7488/406

b) http://www.bmj.com/cgi/content/full/331/7508/94

If we think of our nerves that travel from the pyramidal cells of our brain as long threads dangling from a cortical rooftop then one can comprehend that these threads are bundled through various stations as they descend down to the spinal cord and finally relay to the peripheral nerves that conduct the current that moves our muscles.

So there is a particular station in the brain called pons where this man's threads were suddenly affected two weeks back. What started as a slow dying of the neuronal cells that conduct current through the threads in their downward journey suddenly became an acute shut down (presumably as the myelin sheath covering those neurons and threads were affected). So was this a superaddded acute demyelination on top of a slowly progressive demyelination? Well at this point of time it looks like a secondary demyelination and the pattern seems extremely unlikely for primary demyelination (multiple sclerosis that is).

I had started him on a shot of steroids just in case it was primary inflammatory demyelination and responded like magic. His wife talked a lot today in his presence and I could notice his eye movements become uncomfortable at times particularly when she mentioned how he used to denigrate his brother in law for limping due to polio etc and added that perhaps he was just being punished short term for that and she was confident he would recover completely. I merely nodded in agreement although wished she had more evidence to support her confidence in the future.

December 8

I found him sleeping alone and unguarded (I had forgotten to mention that he had fallen off his bed yesterday). The resident informed me that he was doing well and also able to talk a little.

Wow! Sure enough he managed a 'doctor saab' rather well. His wife has been ecstatic and talks to him more often now and he seems to be happy from whatever I can make out through his expressive eyes.

I have continued the steroids for another two days just in case it is reducing some inflammation that may help to increase a bit more of his power