A 40-year-old woman is brought to the emergency department by her roommate due to significant left leg weakness. The symptom began 3 days ago after her father had a heart attack. There is no personal or family history of neurological disease; surgical history includes liposuction of the thighs and varicose vein removal. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 123/81 mm Hg, pulse is 62/min, and respirations are 14/min. Physical examination reveals symmetric 2+ deep tendon reflexes as well as normal muscle bulk and tone bilaterally in the upper and lower extremities. Laboratory testing and neurologic imaging reveal no abnormalities. Which of the following is the most likely diagnosis?

Question

A 40-year-old woman is brought to the emergency department by her roommate due to significant left leg weakness.  The symptom began 3 days ago after her father had a heart attack.  There is no personal or family history of neurological disease; surgical history includes liposuction of the thighs and varicose vein removal.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 123/81 mm Hg, pulse is 62/min, and respirations are 14/min.  Physical examination reveals symmetric 2+ deep tendon reflexes as well as normal muscle bulk and tone bilaterally in the upper and lower extremities.  Laboratory testing and neurologic imaging reveal no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_360f_f705_9249_173f227bb1c2_MD0001_00 This patient's acute onset of muscular weakness following a stressful incident, normal neurological examination, and negative workup are suggestive of conversion disorder (functional neurologic symptom disorder). Conversion disorder is characterized by symptoms or deficits of voluntary motor and/or sensory function that are incompatible with any recognized neurological condition and cannot be explained by another medical or mental disorder. Common symptoms of conversion disorder may include weakness, paralysis, gait disturbance, blindness, diplopia, aphonia, anesthesia, or nonepileptic seizures (also called psychogenic seizures). The phenomenon of la belle indifférence (ie, incongruous lack of concern about symptoms) has been associated with conversion disorder but is not pathognomonic, occurs at equal frequency in true neurological disorders, and should not be used to make the diagnosis. In fact, patients with conversion disorder may be very distressed by their symptoms. (Choice A) Body dysmorphic disorder involves an excessive preoccupation with perceived defects in physical appearance (eg, nose shape) as opposed to a neurologic deficit (eg, leg weakness). (Choice C) In factitious disorder, patients deliberately falsify symptoms due to their desire to assume the sick role. There is no evidence that this patient is intentionally falsifying her symptoms, and given her recent stress (eg, her father's heart attack), conversion disorder is more likely. (Choice D) Illness anxiety disorder is characterized by excessive fears of having a serious physical disease. The fear is usually due to misinterpretation of bodily symptoms or normal functions (eg, a man with gas pain becoming preoccupied with having colon cancer). (Choice E) Malingering is the purposeful falsification of symptoms for obvious external benefit (eg, a patient feigning hemiparesis to receive disability benefits). (Choice F) Somatic symptom disorder is characterized by excessive and persistent health anxiety and preoccupation with multiple somatic symptoms; it does not present with a clearly incompatible neurological examination. This patient does not express any concern about her impairment and seeks care only when brought in by her roommate, effectively ruling out somatic symptom disorder. Educational objective: Conversion disorder is characterized by neurologic symptoms and examination findings that are incompatible with a known neurological disease. Patients do not consciously produce the symptoms like in factitious disorder or malingering, and the condition may cause significant distress/impairment. __________ References: Conversion disorder - mind versus body: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26155375)

A 40-Year-Old Woman Is Brought to the Emergency Department by Her