Henry Lee-Spinocerebellar ataxia type 3 (SCA-3)-(Australia)

Patient Name: Henry Lee
Gender: Male
Age: 52 years old
Nationality: Australia
Diagnosis: Spinocerebellar ataxia type 3 (SCA-3)

Admission Condition:
The patient was admitted with a primary complaint of "progressive balance disorders accompanied by tremors and involuntary movements for over 2 years," diagnosed as "spinocerebellar ataxia type 3(SCA-3)." The main symptoms included progressive balance disorders, characterized by an unstable gait that was wide-based and slow. He experienced progressive weakness in his limbs, accompanied by tremors, involuntary movements, and pain in the lumbar and back joints, which led to poor sleep. He also had slurred speech and diminished calculation ability. He was currently taking amantadine and gabapentin for treatment. He denied any history of chronic diseases or infectious diseases and had no known drug allergies.

Physical Examination upon Admission:
The patient's blood pressure was 150/99 mmHg, and his heart rate was 85 beats per minute. His nutritional status was moderate, and his skin was dry with no jaundice. No abnormalities were found in the examination of his heart, lungs, and abdomen. The skin temperature of his extremities was low.

Neurological Examination:
The patient was alert but had slurred speech and occasionally experienced chocking when drinking. His memory was fair, but he showed mild impairment in calculation ability. His orientation was normal. Both pupils were equal, round, and 3 mm in diameter, with a reactive light reflex. His visual acuity and visual fields were normal. There was horizontal nystagmus in both eyes, and he was unable to look upward. Facial symmetry was intact, with symmetrical forehead wrinkles and deep nasolabial folds; there was no deviation of the mouth corners. His soft palate elevated strongly, and the uvula was midline. He could puff his cheeks without air leakage and his tongue protruded at midline. Neck and shoulder muscle strength was grade 4. Muscle strength in both upper limbs was grade 3, and in both lower limbs, it was also grade 3. He had poor balance and was unable to stand. Muscle wasting was observed in all limbs, and he had significantly lost weight. Muscle tone in his extremities was generally normal. Deep tendon reflexes were diminished, and pathological reflexes were negative. Both superficial and deep sensations were generally intact. There was tremor and shaking noted in his hands. He had difficulty with finger-to-nose and rapid alternating movements, showing instability in both tests. He was unable to complete the heel-to-shin test. He could not maintain standing with his eyes closed, and was positive for both eyes-open and eyes-closed tests. He was unable to stand without assistance; however, with support from two people, he could barely stand but had a wide-based gait and could not walk. His postural adjustment abilities were poor. There were no signs of meningeal irritation.

Treatment Process:
The patient was admitted with a confirmed diagnosis of "Spinocerebellar ataxia type 3 (SCA-3)." He was given CAST therapy along with a combined stem cell treatment consisting of neural stem cells and mesenchymal stem cells. This comprehensive treatment aims to repair the cerebellar and spinal cord nerve damage, provide neuroprotection, improve the internal environment, and regulate the immune system. Additionally, rehabilitation therapy was implemented to support his recovery.

Post-Treatment Progress:
After treatment, the patient showed significant improvement in neurological function. His speech has become clearer and faster. His calculation ability has improved compared to before. He has experienced a significant reduction in nerve pain and has discontinued gabapentin. The horizontal nystagmus in both eyes has noticeably decreased, and his upward gaze has improved. His balance has significantly improved, with better postural adjustment abilities. He can now stand up independently from a seated position and maintain independent standing, with a narrower base compared to before. He can walk slowly for about 5-10 meters on his own. His performance on the finger-to-nose test for both upper limbs is nearly normal, and he has shown significant improvement in the rapid alternating movement and finger-to-finger tests. His limb movement speed and agility have notably increased. He can now successfully complete heel-to-shin test. There is an increase in muscle strength, with both upper limbs grade 4 and both lower limbs also grade 4. The tremors in his limbs have significantly reduced. There has been a notable improvement in the skin temperature of his extremities.