GENERAL MEDICINE CASE 6

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Case: A 45 yr old female patient came to opd with b/l lower limb weakness.

 

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

You can find the entire real patient clinical problem in this link here..

https://doctorjaswitha.blogspot.com/2020/05/interns-log-book.html

The problems in order of priority I found are 

1) B/l lower limb weakness for past 5 months

2) Headache for past 2years

3)multiple body pains,disturbed sleep,

4)Auditory hallucinations ,double vision. 

Other complaints

Diagnosed as depression without psychotic features

She was on Bulotin , Esihan's plus for 1 week 

Explanation of above complaints in detail.

1-WEAKNESS OF LOWERLIMBS AND SWAYING 

Onset:sudden in onset

Duration :since 5 months

Associated conditions : 

                    -NO Tingling and numbness

                   -history of sudden fall and slurring of speech for few days associated with swaying.

Swaying:

Complaints of swaying to right/left side unable to get up from bed, giddiness on lying down, standing,  walking.

mostly associated with cerebellum,may be posterior cerebellar artery ischemia.

Possible diagnosis:

1)A sudden fall may be indicative of vascular cause probably due to stroke or ischemia or infarcts in the brain.  

2)Weakness may be caused by any one of the following related to   vascular system,muscle or nervous system.

If Artery related

As in case of peripheral artery disease and varicose veins there will be pain,leg skin atrophy,and claudication,telengectasia. As there are no signs of this artery are ruled out.

#if any blood vessel in the brain undergoes infarction then there is a chance of sudden stroke and paralysis of limbs.

If suspecting  nervous system related?

May be it is related to nerves because from the history there is history of weakness tingling and numbers in the feet

To understand the nerve related issue A thorough CNS EXamination is done and following are results.

CNS-EXAMINATION

CNS Examination

Higher mental functions-

Consciousness present

Orientation to time ,place and person present

Memory -immediate ,recent and remote present

Speech and emotions -intact

Cranial nerves -

Facial nerve-effected on left side

Motor System-

Tone  -hypotonia present in rt upper and lower     limbs

Power -

                   UL . Rt.       Lt

                         -4/5.     -4/5

                   LL   

                          5/5.      5/5

 Gait - ataxic gait

 Reflexes -

 Superficial reflexes - abdominal reflex - absent

           Plantar extensor reflex present

 Deep reflexes - exaggerated

1.ANATOMICAL LOCATION OF THE PROBLEM

 From the above CNS examination findings we can anatomically localise it as UMN LESION because there is hyperreflexia(exaggerated reflexes).

Specific localisation.

Now according to the facial nerve damage the umn lesion is confirmed as above the level of pons.

That is we have to find the exact location of lesion by rule out method.

Possible lesions may be at spinalcord,brainstem,cerebral cortex,thalamus,internal capsule etc.

I think it may be in the cortex region because lower limbs are more affected than upper limbs according to homunculus.

INVESTIGATIONS DONE:

CAROTID DOPPLER,MRI are specific to this case.

According to colour Doppler test there is soft plaque in the left carotid bifurcation

MRI says that ACA,MCA,PCA are normal so there is no vasculitis cause.

MRI differential diagnosis

1)NEUROMYLITIS OPTICA

2)Multiple sclerosis

3)vasculitis 

4)Neurosarcoidosis

5)Neuro-behcets disease

1- MULTIPLE SCLEROSIS (demyelination disorder)

we can rule out this as there is no horse shoe ring enhancement and Dawson fingers and also plaques ,and no triradiate hyperintensity in centre of ponsin MRI .

Plaques can occur anywhere in the central nervous system. They are typically ovoid in shape and perivenular in distribution

https://radiopaedia.org/articles/multiple-sclerosis

2- vasculitis- 

we can rule out this also because all the ACA MCA PCA arteries are normal in MRI and also clinically there is no sudden onset of paralysis.

3-neuromylitis optica

Neuromyelitis optica, also called NMO or Devic's disease, is a rare yet severe demyelinating autoimmune inflammatory process affecting the central nervous system. It specifically affects the myelin, which is the insulation around the nerves. NMO mainly affects the spinal cord and the optic nerves -- the nerves that carry signals from the eyes to the brain. As a result, the disease can cause paralysis and blindness. As there are no clinical symptoms above.. we can rule out this.

https://www.google.com/amp/s/www.hopkinsmedicine.org/health/conditions-and-diseases/neuromyelitis-optica%3famp=true

4-Neurosarcoidosis

The radiographic features of neurosarcoidosis can be thought of as occurring in one or more of five compartments. From superficial to deep they are:

• skull vault involvement 
• pachymeningeal involvement
• leptomeningeal involvement (seen in up to 40% of cases ¹) 
  • pituitary and hypothalamic involvement
  • cranial nerve involvement
• parenchymal involvement (most common)
• As there is no signs of this we can rule out Neurosarcoidosis.

5-NEURO -BEHCETS DISEASE

Neurological involvement may occur in the course of the disease and have two major forms: vascular and parenchymal . Parenchymal lesions lead to inflammatory lesions in the brain stem, diencephalon, basal ganglia and less frequently, the spinal cord and cerebellum. The cerebral cortices seem to be spared. They usually manifest as bilateral pyramidal signs, unilateral hemiparesis, behavioural changes, sphincter disturbances and headache.

The MRI findings of our case were in keeping with neuro-BD with the classical involvement of brain . These parenchymal lesions are thought to represent vasculitis of small vessels, mainly venular involvement. The differential diagnosis radiologically may include diseases such as neurosarcoidosis, small-vessel vasculitis of brain and viral infections.

Reference link:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584512/

http://www.neurologyindia.com/article.asp?issn=0028-3886;year=2018;volume=66;issue=6;spage=1619;epage=1628;aulast=Caruso

https://radiopaedia.org/articles/behcet-disease-cns-manifestations-1

Treatment

The treatment of parenchymal neuro-BD consists of glucocorticoids (high-dose pulse intravenous and/or oral) and azathioprine . In refractory cases, anti-TNF alpha therapy with infliximab has shown to be of benefit..!

Present treatment.

 1. Ink.Methyprednisolone 1gm in 100 ml NS OD

 2. Inj.Zofer 4 mg /i.v /sos

 3. Tab.PCM 650mg/PO/sos

 4.Tab.Atorvastatin 20 mg/PO to dissolve soft plaques in left carotid bifurcation.

 5. Physiotherapy of right upper limb and lower limb

 6. BP charting 4 the hrly

                THANK YOU.