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.