Ms. Eunsook-Cerebellar Ataxia-(Korea)
Before treatment: Admission PE: Nervous System Examination: Treatment: Post-treatment:
Name: Ms. Eunsook
Sex: Female
Nationality: Korean
Age: 42Y
Diagnosis: Cerebellar ataxia combined with retinitis pigmentosa
The patient had balance problems 10 years ago, she was unable to walk well, fell down sometimes, felt stiff in her lower limbs, sometimes couldn’t speak clearly and she spoke slowly. She was diagnosed with cerebellar atrophy, SCA-7 combined with retinitis pigmentosa. 5 years ago she could move her arms well. At present her balance is bad and she is unable to stand or walk by herself well. She is able to walk around her house with walking aids. Her arms are basically normal, she is able to dress, wash her face and brush her teeth by herself. She can eat well, her speaking ability is bad as she speaks slowly and in an unclear manner.
Her spirit is normal, she sleeps around 12 hours a day, her diet, urination and defecation functions are normal.
Bp: 113/73mmHg, Hr: 77/min. There is no injury or bleeding spots on her skin and mucosa, no blausucht and no tonsil swelling. Chest development is normal, the respiratory sounds in both lungs were clear and there was moist rales. The heart beat is powerful with regular cardiac rhythm and no obvious murmur in the valves. The abdomen was soft with no masses or tenderness. Her liver and spleen were normal by touch examination. There was no edema of the legs
Patient was alert with slurred and slow speech. The memory and orientation abilities were normal, her calculation ability was not good enough. Both pupils were equal in size and round, diameter of 2.5 mm and react well to light. The eyeballs cannot move upward well but other movements were normal. She could not distinguish color well. The eyesight examination with the standard chart: both eyesight readings were 0.06 at 1.5cm. At 80cm the right eyesight was 0.15, left eyesight was 0.12. There was photophoby. The eyes fundus examination: right side was slightly yellow with exudation and a lot of osteoid deposit, left side was mild yellow with an unclear macula border and a few osteoid deposits at the edges. A/V was 1/3. Bilateral forehead wrinkle is symmetrical, showing teeth is normal, tongue is in middle position and she could close her eyes powerfully. Chewing ability was normal, there was no tongue muscle tremor and her tongue can touch the cheek powerfully. She could bulge her cheeks without air leakage. The arm muscle power was 5 degrees, grip force was 5 degrees. The leg muscle power was 5 degrees and she could walk with a walker. Arm muscle tone was normal, leg muscle tone was slightly higher., The tendon reflex of the arms, patellar tendon reflex and Achilles tendon reflex were active. Bilateral Hoffmann signs were positive, right side Rossilimo sign was positive, bilateral Babinski signs were negative. Her sensory system examination was normal, the finger to nose test was slow and not accurate, her fast alternate movement was clumsy and she could perform the finger opposite movement slowly. The heel-knee-tibia test was clumsy, the Romberg sign was positive and the Meningeal irritation sign was negative.
After the admission she received 3 nerve regeneration treatments (neural stem cells and mesenchymal stem cells) to repair her damaged nerves, replace dead nerves, nourish nerves, regulate her immune system and improve blood circulation. This was done with rehabilitation training.
After 14 days treatment her speech and balance control ability improved, she spoke louder and clearer. The movement of her hands was better, the fast alternate movement was much more flexible and her heel-knee-tibia test was much more stable. She could now stand without support for more than 30 seconds. The left eyesight improved and reached 0.15 at 80cm. The eyes fundus blood circulation was much better by examination.
