Juan Carlos Nietch-Spinocerebellar ataxia type 1-Hyperlipidemia-(United States)

Patient Name: Juan Carlos Nietch
Gender: Male
Age: 53 years old
Nationality: United States
Diagnosis: 1. Spinocerebellar ataxia type 1 (SCA1) 2. Hyperlipidemia

Admission condition:
The patient was admitted to the hospital due to "abnormal gait and unsteady walking for 14 years, worsened with unclear speech for 7 years" with the diagnosis of spinocerebellar ataxia (SCA1). He had a slow onset and progressive worsening. He had lower limb balance impairment and an unsteady gait. He had unclear speech. He had no dizziness, headaches, bowel or bladder dysfunction, or limb weakness. In the past, he underwent uvulopalatopharyngoplasty in 2006 for snoring, which improved his symptoms but he still could not drink with a straw. He had subcutaneous testosterone pellets implanted since approximately 2015, replaced every six months. He had sciatica for 21 years and occasionally took analgesics for pain relief.

Physical examination upon admission:
The patient’s blood pressure: 111/76 mmHg, his heart rate: 78 beats per minute, his respiratory rate: 19 breaths per minute, his blood oxygen saturation: 95%. He had normal development and moderate nutrition. No cyanosis was observed in his lips, no congestion in his oral and pharyngeal mucosa, and no enlarged tonsils. His chest was symmetrical, with clear breath sounds in his both lungs and no obvious dry or wet rales. No obvious cardiac heave was observed in the precordium, and his heart sounds were strong, regular, with no obvious murmurs over the cardiac valve areas. His abdomen was soft, without tenderness or rebound tenderness.

Neurological examination:
The patient was alert and oriented, with unclear and explosive speech. His memory, calculation, and orientation were basically normal. His pupils were equal in size, approximately 3mm in diameter, with sensitive light reflexes, no obvious nystagmus, and normal visual acuity and visual fields. His forehead wrinkles were symmetrical, bilateral nasolabial folds were deep, his mouth and angles of the mouth were not deviated, his soft palate was lifted forcefully, and the uvula was not seen. He could turn his neck and shrug his shoulders symmetrically with strength. His limb muscle strength was grade 5, and muscle tone was basically normal. His deep tendon reflexes were hyperactive, abdominal reflexes were normal, and pathological reflexes were negative. His deep and superficial sensations were normal. He had unsteady performance in the finger-to-nose test, clumsiness in the rapid alternating movement test, and slow completion of the heel-to-shin test. He had a positive Romberg's sign. He had difficulty rolling over and sitting up independently, slowly. He could not stand or walk independently. There were no signs of meningeal irritation.

Treatment process:
The patient was diagnosed with spinocerebellar ataxia type 1 (SCA1) upon admission. He received mesenchymal stem cells + neural stem cells + CAST treatment to increase the number of cerebellar and spinal cord nerve cells, repair nerve damage, improve blood circulation and immune regulation in the cerebellum and spinal cord, and provide nutritional support to the nerves. Rehabilitation therapy was also provided.

Post-treatment:
The patient's balance and motor functions significantly improved. He could roll over and sit up independently, and his movement speed increased significantly. The speed and accuracy of the heel-to-shin test on both sides improved compared to admission. He could stand independently and walk short distances (approximately 10 meters) on his own. His bilateral upper limb coordination improved, with increased hand dexterity. The finger-to-nose test on his both sides became more stable and accurate, and the speed and flexibility of rapid alternating movements improved. His muscle reflexes transitioned from hyperactive to active. His energy, physical fitness, and endurance improved.