Medical Mystery of the Week

      You have received your COVID19 immunizations but continue to practice  telemedicine.    You are sent a video of a neurologic test being performed on a 70-year-old man who is complaining of a gait disturbance. What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend?
DIAGNOSIS: sustained clonus, a sign of upper motor neuron (UMN) disease. This patient has a spastic gait due to weakness and spasm of his adductors and calf muscles. His gait is "stiff-legged" and accompanied by scissoring (crossing of legs while walking) and instability. An additional clue to his diagnosis is given in the second video below.

Sustained clonus (maintained for >7 contractions) which is rated as a 5+ reflex on a scale of 0-5 (left image). A video of the patient's head, neck and torso is shown in the right image, which shows muscle fasiculations, a sign of lower motor disease. 

DIAGNOSIS: Amyotrophic lateral sclerosis (ALS) with characteristic combined upper and lower motor neuron disease.