Persistent Dizziness and Visual Disturbances: A Neurological Perspective

Q: Persistent Dizziness and Visual Disturbances: A Neurological Perspective

Hello： The above symptoms are suspected to be autonomic neuropathy. <br>It is recommended to visit a neurology outpatient clinic.

Dizziness and inability to focus?

Hello Doctor: Since November of last year, I have been experiencing dizziness and a feeling of heaviness in my head in the afternoons (not vertigo, but a dull sensation), along with unusual fatigue and low-grade fever.
I subsequently underwent various examinations across multiple specialties (neurology, cardiology, pulmonology, rheumatology, endocrinology, hematology-oncology, and infectious diseases), including blood tests, EEG, evoked potentials, head and neck MRI, and sleep studies, none of which revealed significant abnormalities (the brain MRI showed nonspecific white matter changes, and the sleep study indicated that my blood oxygen levels fluctuated between 88-96 during the first half hour before sleep, but remained above 96 during sleep; N3 sleep was 0, and my attending physician said not to worry about it).
Eventually, I sought help from a psychiatrist at the end of the year and started taking Amisulpride and Rifampicin.
By mid-February, my fatigue and low-grade fever improved, but I still experienced afternoon dizziness and heaviness in my head.
However, starting from a certain day in late February, the dizziness and heaviness transformed into "dizziness with blurred vision," as if my entire head were being covered, lasting for 24 hours, sometimes accompanied by low-grade fever.
Recently, the dizziness and blurred vision have worsened, and I have noticed that my eyes struggle to focus, whether on moving images or transitioning from near to far; my eyes often cannot keep up.
Walking down the street, I feel very disoriented and unable to process anything in front of me (feeling dazed); additionally, I have recently experienced hoarseness and body aches at night.
In summary, my condition has been worsening.
I sought further evaluations from ophthalmology, neurology, otolaryngology, rheumatology, and infectious disease specialists.
The ophthalmologist stated that my eyes were fine but somewhat dry (eye drops were ineffective), the otolaryngologist found no issues and could not determine the cause of my hoarseness; immunology tests did not yield any antibodies, and the infectious disease specialist found no signs of infection.
Neurology conducted visual evoked potentials and EEG, both of which were normal.
I inquired with the neurologist whether this could be neuromyelitis optica, chronic neuropathy, encephalitis, or myasthenia gravis, but the doctor said it did not appear to be the case and advised me to return to psychiatry.
I would like to ask the doctor if psychological issues could cause such symptoms? What exactly is this condition? Could there be other diseases that I have not yet identified? I am very troubled by this (unable to work, even daily living activities are problematic), and I hope the doctor can provide me with some advice.
Thank you very much.

Haizi de ba, 30~39 year old female. Ask Date: 2022/05/12

Dr. Cai Zongzhang reply Neurology

Hello: The above symptoms are suspected to be autonomic neuropathy.
It is recommended to visit a neurology outpatient clinic.

Reply Date: 2022/05/12

More Info

Persistent dizziness and visual disturbances can be complex symptoms that may arise from various underlying conditions. Your case, which has evolved over several months and involved extensive testing across multiple specialties, suggests a multifaceted issue that could be neurological, psychological, or even a combination of both.

Firstly, it’s important to understand that dizziness can manifest in different forms, such as vertigo (a spinning sensation), lightheadedness, or a feeling of imbalance. In your case, you describe a dull, persistent sensation of dizziness accompanied by fatigue and low-grade fever, which can complicate the diagnostic picture. The fact that extensive neurological evaluations, including MRI and EEG, returned normal results is reassuring but also leaves us searching for other explanations.

The presence of non-specific white matter changes on MRI could indicate a variety of conditions, including small vessel disease, migraine-related changes, or even demyelinating diseases, but these typically require correlation with clinical symptoms and further investigation. Your mention of fluctuating oxygen saturation during sleep could suggest sleep apnea or other sleep-related disorders, which can contribute to daytime fatigue and cognitive disturbances.

The transition from general dizziness to a more specific "head dizzy" sensation, along with difficulty focusing your vision, raises the possibility of a neurological condition affecting visual processing or coordination. However, since your visual evoked potentials and other eye examinations returned normal, it may suggest that the issue is not purely ocular or related to the optic nerve.

The symptoms you describe, including feeling disoriented and unable to process visual information, could also be linked to psychological factors. Anxiety and depression can manifest physically, leading to symptoms such as dizziness, fatigue, and cognitive difficulties. It’s not uncommon for patients with chronic physical symptoms to develop secondary psychological issues, which can further exacerbate their condition. The medications you were prescribed by the psychiatrist, such as antidepressants, can sometimes help alleviate these symptoms, but it may take time to find the right balance.

Given the complexity of your symptoms and the lack of clear findings from your medical evaluations, it may be beneficial to consider a multidisciplinary approach. This could include:
1. Neurological Re-evaluation: A follow-up with a neurologist who specializes in complex cases may provide further insights. They might consider additional tests, such as a lumbar puncture, to analyze cerebrospinal fluid for inflammatory markers or other abnormalities.

2. Psychiatric Support: Since you have already consulted a psychiatrist, continuing to explore this avenue could be beneficial. Cognitive-behavioral therapy (CBT) or other therapeutic approaches may help manage the psychological aspects of your symptoms.

3. Physical Therapy: Vestibular rehabilitation therapy (VRT) may help address balance issues and dizziness, particularly if there is a vestibular component to your symptoms.

4. Lifestyle Modifications: Ensuring adequate hydration, nutrition, and sleep hygiene can also play a significant role in managing symptoms. Regular physical activity, as tolerated, can improve overall well-being and reduce fatigue.

5. Holistic Approaches: Mindfulness, meditation, and relaxation techniques can help manage stress and anxiety, which may be contributing to your symptoms.

In conclusion, while your symptoms are indeed troubling and have significantly impacted your quality of life, they do not point to a single, easily identifiable condition. A comprehensive approach that includes both medical and psychological support may provide the best pathway to relief. It’s crucial to maintain open communication with your healthcare providers and advocate for your health as you navigate this challenging situation.

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