A 28-year-old man comes to the office because of several days of unsteadiness when walking. Yesterday, the patient fell down when walking to the kitchen to make dinner. He says that he feels unsteady when walking because it seems as if stationary objects are moving around throughout his visual field. The patient denies head trauma and did not lose consciousness at any time. He does not have headache, dizziness, focal neurologic deficits, urinary incontinence, chest pain, or palpitations. His medical history is remarkable for cystic fibrosis, which has been complicated by multiple pulmonary infections and pancreatic insufficiency. Two weeks ago, he was prescribed ampicillin and gentamicin for the treatment of a pulmonary infection. The patient also takes supplemental pancreatic enzymes. He does not use tobacco, alcohol, or illicit drugs. He is sexually active with one female partner and does not regularly use condoms. His temperature is 36.9°C (98.5°F), pulse is 72/min, and blood pressure is 115/70 mm Hg. His BMI is 25 kg/m2. The patient is alert and oriented, and his speech is normal. Neurologic examination shows normal muscle strength and sensation in all extremities. Deep tendon reflexes are 2+ throughout. The patient's gait is unsteady when he is asked to walk across the room. Hearing is decreased in the left and right ears on whisper test. The patient is then asked to focus on a chart on the wall; during rapid head movement away from this target, his eyes briefly move away from the target before there is a horizontal saccade back toward it. There are no visual field deficits and his pupils are equal and reactive to light. Serum laboratory studies are within normal limits. Which of the following is the most likely cause of this patient's current symptoms?A. Aminoglycoside toxicityB. Benign paroxysmal positional vertigoC. Ménière diseaseD. Pituitary adenomaE. Tertiary syphilisF. Vitamin B12 (cobalamin) deficiencyG. Vitamin E (tocopherol) deficiency
Question
A 28-year-old man comes to the office because of several days of unsteadiness when walking. Yesterday, the patient fell down when walking to the kitchen to make dinner. He says that he feels unsteady when walking because it seems as if stationary objects are moving around throughout his visual field. The patient denies head trauma and did not lose consciousness at any time. He does not have headache, dizziness, focal neurologic deficits, urinary incontinence, chest pain, or palpitations. His medical history is remarkable for cystic fibrosis, which has been complicated by multiple pulmonary infections and pancreatic insufficiency. Two weeks ago, he was prescribed ampicillin and gentamicin for the treatment of a pulmonary infection. The patient also takes supplemental pancreatic enzymes. He does not use tobacco, alcohol, or illicit drugs. He is sexually active with one female partner and does not regularly use condoms. His temperature is 36.9°C (98.5°F), pulse is 72/min, and blood pressure is 115/70 mm Hg. His BMI is 25 kg/m2. The patient is alert and oriented, and his speech is normal. Neurologic examination shows normal muscle strength and sensation in all extremities. Deep tendon reflexes are 2+ throughout. The patient's gait is unsteady when he is asked to walk across the room. Hearing is decreased in the left and right ears on whisper test. The patient is then asked to focus on a chart on the wall; during rapid head movement away from this target, his eyes briefly move away from the target before there is a horizontal saccade back toward it. There are no visual field deficits and his pupils are equal and reactive to light. Serum laboratory studies are within normal limits. Which of the following is the most likely cause of this patient's current symptoms?A. Aminoglycoside toxicityB. Benign paroxysmal positional vertigoC. Ménière diseaseD. Pituitary adenomaE. Tertiary syphilisF. Vitamin B12 (cobalamin) deficiencyG. Vitamin E (tocopherol) deficiency
Solution
The most likely cause of this patient's symptoms is A. Aminoglycoside toxicity.
The patient's history of cystic fibrosis and recent treatment with ampicillin and gentamicin for a pulmonary infection are key clues. Aminoglycosides, such as gentamicin, are known to be ototoxic, which can result in both vestibular and cochlear damage. Vestibular toxicity can present as unsteadiness, imbalance, or problems with spatial orientation, as seen in this patient. Cochlear toxicity can present as tinnitus or hearing loss, which is also seen in this patient.
The other options are less likely given the patient's history and presentation. For example, benign paroxysmal positional vertigo typically presents with brief episodes of vertigo triggered by changes in head position, which is not described here. Meniere's disease is characterized by episodic vertigo, sensorineural hearing loss, tinnitus, and aural fullness, but this patient's symptoms are not episodic and there is no mention of tinnitus or aural fullness. Pituitary adenoma, tertiary syphilis, and vitamin deficiencies would not explain this patient's specific combination of symptoms and history.
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