Case Challenge....Difficult one

**jmj11** · 04-14-2012, 02:13 PM

Originally Posted by physasst

I'll only add this, we had reached a diagnosis of "Vertigo, NOS-Etiology Unclear", and had our PT in the ER evaluate the patient. The PT made the diagnosis. Neither I, nor the attending (who is chair of the department and past ACEP educator of the year) had EVER heard of the illness. In fact, I'm writing it up as well.

Okay, if PT figured it out, then I suggest they said it was "Mal De Dismbarquement Syndrome" but is there good scientific basis for this? While there may be many cases reported, is there an scientific explanation?

**physasst** · 04-14-2012, 02:25 PM

Originally Posted by jmj11

Okay, if PT figured it out, then I suggest they said it was "Mal De Dismbarquement Syndrome" but is there good scientific basis for this? While there may be many cases reported, is there an scientific explanation?

DING DING DING....We have a winner. They believe that it is a calibration reset of your equilibrium. Patients with MDD will often have resolution of their symptoms when they go back onto a boat or plane. They have essentially reset their equilibrium and when on land, have symptoms.

This is from a Journal of Neurology paper...

Of 64 patients(75% women) identified with MdD, 34 completed follow-up questionnaires and interviews in 2006. Most patients had normal neurological exams, ENGs and brain MRIs. The average age of the first MdD episode was 39+/-13 years. A total of 206 episodes were experienced by 64 patients. Of these, 104 episodes (51%) lasted>1 month; 18%, >1 year; 15%, >2 years; 12%, >4 years, and 11%, >5 years. Eighteen patients (28%) subsequently developed spontaneous episodes of MdD-like symptoms after the initial MdD episode.There was a much higher rate of migraine in patients who went onto develop spontaneous episodes(73%) than in those who did not(22%). Subsequent episodes were longer than earlier ones in most patients who had multiple episodes.Re-exposure to passive motion temporarily decreased symptoms in most patients (66%).Subjective intolerance to visual motion increased (10% to 66%)but self-motion sensitivity did not(37% to 50%) with onset of MdD.

From another J or Neuro article (Clark and Quick, 2011).

http://www.springerlink.com/content/k470100621353l10/

While the etiology of persistent MdDS is poorly understood, it does not appear to originate from vestibular dysfunction as vestibular tests are normal
and the symptoms do not respond to vestibular therapy. Rather, MdDS appears to be a disorder of neuroplasticity and sensory rearrangement.

**marilynpac** · 04-14-2012, 03:45 PM

Nice one Michael...you really made everyone put their thinking caps on tightly......but this zebra is more like the zebra's cousin...IMO...

**ventana** · 04-14-2012, 07:57 PM

Originally Posted by jmj11

"Mal De Dismbarquement Syndrome" ?

What they heck language is that in? Seriously I have never even heard that - darn now I gotta go look it up and learn at least a little bit about it....... man is medicine exciting and humbling all at once.

pause to read/research

Oh - I have heard that called landsick by sailors in the carribean (father had a sail boat) but usually they just said you had a difficult time getting your land legs back....... those darn french come up with new stuff all the time - seriously though great case - how did the PT know this? Were the vestibular rehab PT?

**Mastersoldier13** · 04-16-2012, 12:55 AM

haha I was going to say landsickness but someone beat me to it

**True Anomaly** · 04-16-2012, 07:33 AM

Great case Mike. We unfortuantely don't have the ability to have PT come to the ER to do an evaluation, so we end up placing them in observation in order to get PT eval/treat. And prior to working in our observation unit, I had no idea that there was such an animal as "vestibular physical therapy"

**ventana** · 04-16-2012, 07:35 AM

Originally Posted by True Anomaly

Great case Mike. We unfortuantely don't have the ability to have PT come to the ER to do an evaluation, so we end up placing them in observation in order to get PT eval/treat. And prior to working in our observation unit, I had no idea that there was such an animal as "vestibular physical therapy"

wow you must not have Gentiva home services in your area - all they do it talk about VPT.... over and over and over....

**True Anomaly** · 04-16-2012, 08:09 AM

Originally Posted by ventana

wow you must not have Gentiva home services in your area - all they do it talk about VPT.... over and over and over....

Nope, never heard of 'em. Would that be something present in a more affluent neighborhood?

**physasst** · 04-16-2012, 09:19 AM

Originally Posted by True Anomaly

Great case Mike. We unfortuantely don't have the ability to have PT come to the ER to do an evaluation, so we end up placing them in observation in order to get PT eval/treat. And prior to working in our observation unit, I had no idea that there was such an animal as "vestibular physical therapy"

We have PT stationed in the ED on M-F from 8-5. We just started it about a year ago as a pilot. It worked so well that we are considering expanding their hours. They see back pain, dizziness, knee, ankle....all the musc. stuff.

I have nothing but good things to say about their service.

**cecilia** · 04-16-2012, 09:58 AM

I saw an episode of Mystery Diagnosis where there was a woman diagnosed (at the end) with Disembarquement syndrom. Her dizziness disappeared once she started driving her car, but symptoms would return as soon as she stopped driving. Was the same happening to your patient?
I can't help but notice that she is 43 and also having some "perimenopausal" symptoms. Were her hormone levels checked? including thyroid?