History/Examination
A 57-year-old male presented to the Emergency Department recurrently over a 4-week period with dizziness, headache and subsequent nausea and vomiting. He had no relevant past medical or travel history. He worked as a traffic warden, was a smoker with a 30-pack year history and consumed minimal alcohol. He had been investigated thoroughly on his first two presentations, having undergone a CT and MRI Head (Figure 1 and 2) and admission with assessment by a consultant neurologist. With a history descriptive of positional vertigo, torsional nystagmus on left lateral gaze and a positive Semont Diagnostic Manoeuvre (and resolution with Epley’s manoeurvres), he had been diagnosed with BPPV.
Following his diagnosis with BPPV he presented two further times to the Emergency Department, being admitted on the fourth presentation due to significant dehydration and progressive weight loss, ascribed to the nausea and vomiting. His blood tests on this occasion demonstrated a significant neutrophilia, a raised urea (in keeping with clinical dehydration), and an unexplained elevated Alkaline Phosphatase (317 U/L). He described no additional symptoms, abdominal examination was unremarkable and he did not display any new motor weakness. His diagnosis of BPPV was initially maintained until, on further exploration, he was found to now have features of cognitive impairment with an abbreviated mental test score of 6/10, and an inability to follow three stage commands. Further investigations were subsequently arranged.