Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with progressive gait instability, limb ataxia, and fine motor incoordination. Symptoms are insidious in onset and chronic in nature. No family history of hereditary ataxias. Patient reports associated gastrointestinal symptoms including [bloating/diarrhea/abdominal pain], though GI symptoms may be absent. No history of alcohol abuse or neurotoxic exposure.
Clinical Examination Findings
Neurological examination reveals gait ataxia with a wide-based stance. Dysmetria and dysdiadochokinesia noted on finger-to-nose and heel-to-shin testing. Ocular examination shows gaze-evoked nystagmus and impaired smooth pursuit. Deep tendon reflexes are [normal/diminished]. Sensory examination is [intact/impaired]. No evidence of cognitive decline or parkinsonism.
Treatment Protocol
Strict, lifelong gluten-free diet (GFD) is the primary therapeutic intervention. Referral to a specialized dietitian is mandatory to ensure complete elimination of wheat, barley, and rye. Monitor anti-transglutaminase (tTG-IgA) and anti-gliadin peptide (AGA-IgG) titers for adherence. Consider physical therapy for gait training and balance rehabilitation. Follow-up neurological assessment scheduled in [3/6] months to evaluate stabilization of ataxia.