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Multiple Sclerosis Presentation

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Page 1: Multiple Sclerosis Presentation
Page 2: Multiple Sclerosis Presentation

Case of 34y/o ♀ c/c neurological Sx’s starting 1 and ½ yrs ago. Pt had sudden onset of numbness in the Lt. arm &descending down the leg after strenous ex’s which caused difficulty in walking. This subsided within a few wks then she developed a relapse in both L/E which also caused difficulty in walking for few wks which became normal within 3wks of taking medication. Episodes of relapse and remissions were frequent in U/E and L/E having weakness along with abnormal vision, diplopia, & abnormal pupil responses with relative afferent pupil defect on Lt. Pt also developed loss of pinprick sensation in level of T4-T5 & was moody with episodes of anxiety &depression.

Page 3: Multiple Sclerosis Presentation

Past Medical Hx:

• No h/o previous surgery

• No h/o neurological disorders , DM, HTN or cardiac diseases.

• Non-smoker with sedentary lifestyle

Page 4: Multiple Sclerosis Presentation

• GCS 15/15• Orientation: Oriented,

alert and cooperative• Speech: Dysarthric with

slurred speech, at times comprehensible.

• Cognitive: Emotional symptomatology mainly depression and a decline in recent memory and attention span.

Page 5: Multiple Sclerosis Presentation

• All CN’s intact except: • CN 2: Funduscopic

examination reveals optic disk palor bilaterally.

• CN 3: Pupillary responses are abnormal.

• Extraocular movements are full without nystagmus.

Motor examination• Paresis in the left U/E 4/5 but

right U/E reveals normal muscle power.

• Paresis of the right and left L/E 3/5.

Page 6: Multiple Sclerosis Presentation

• Difficulty in coordination in U/E and L/E. ( rapid alternating movements, finger to nose and heel to shin)

.

Page 7: Multiple Sclerosis Presentation

• Hyperreflexia of DTRs of both U/E and L/E

• Bilateral Babinski present.

Page 8: Multiple Sclerosis Presentation

• Mild vibratory sensation lost in the distal U/E and L/E.

• Intact to pin prick, light touch and temperature.

• Intact sensation of the face.

• Proprioception loss in both L/E to the level of the ankles.  

Page 9: Multiple Sclerosis Presentation

• The patient has a positive Romberg's sign therefore patient has mild ataxia.

Page 10: Multiple Sclerosis Presentation

• MRI scan report revealed abnormal and CSF analysis showed the presence of oligoclonal bands,when a laboratory procedure called CSF electrophoresis was taken & very high ratio of IgG to albumin.

• The term oligoclonal bands means the presence in CSF of two or more protein bands of a specific immunoglobin (IgG) that have greater intensity than in the concurrent serum sample. This pattern of banding is seen in patients with ….?

Page 11: Multiple Sclerosis Presentation

• * MRI transverse brain section: shows multiple periventricular and white matter lesions.

• There are 10 multiple patches of myelin) around different areas of the brain (white & gray matter junction, brain stem, & cerebellum).

Page 12: Multiple Sclerosis Presentation

• * MRI sagittal brain section: shows (multiple lesions (arrows) that radiates from the surface of the lateral ventricles).

Page 13: Multiple Sclerosis Presentation

• * MRI paired transverse brain slices: show many white-matter lesions (arrows). At the bottom it shows gadolinium (an intravenous dye) contrast & enhancement of one of the lesions (arrow) indicating permeability of the blood-brain barrier & disease activity in the past 2 mnths of pt’s life.

Page 14: Multiple Sclerosis Presentation

• * MRI of the patient’s spinal cord (sagittal & transverse sections): shows many white lesions in some areas.

Page 15: Multiple Sclerosis Presentation

• Spinal tap (lumbar puncture): a small sample of CSF was removed within the patient’s spinal canal at the level of (L4-L5) that showed CSF IgG concentration is increased relative to other CSF proteins (e.g., albumin) and CSF gel reveals oligoclonal bands that are not present in a matched serum sample.

• Visually Evoked Potential (VEP): showed abnormal result (slow optic nerve conduction response).

• Brain Stem Evoked Response (BAER): showed (normal speed & response of transmission to CN 8).

• Somatosensory Evoked Potential (SSEP): showed abnormality in all 4 limbs.

Page 16: Multiple Sclerosis Presentation

What is the Possible Diagnosis?

Page 17: Multiple Sclerosis Presentation
Page 18: Multiple Sclerosis Presentation

Thank You