Limb Weakness and Vision Loss in a 30-Year-Old Man

Sumaira Nabi, MBBS; Shahzad Ahmed, MBBS; Muhammad Tariq, MBBS, FRCP


November 10, 2015

Physical Examination and Workup

On physical examination, the patient is conscious and oriented to time, place, and person. He has a regular pulse of 86 beats/min, a blood pressure of 110/80 mm Hg, a respiratory rate of 16 breaths/min, and an oral temperature of 98.6°F. His Glasgow Coma Scale score is 15/15. The visual acuity in the patient's right eye is reduced to counting fingers only, whereas the acuity is 6/12 in his left eye. He also has a relative afferent pupillary defect on the right side, with optic atrophy on funduscopic examination. Funduscopy of the left eye reveals mild disc pallor (Figures 1-4).

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The patient has spastic paraplegia and upper extremity diparesis. He has hyperreflexia with bilateral extensor plantar response. He has a sensory level at C6/C7. Signs of meningeal irritation are absent. His abdomen is soft and nontender, and no clinical evidence suggests organomegaly or ascites. Bowel sounds are audible. The patient's precordial examination reveals normal heart sounds. Auscultation of the lung fields reveals normal vesicular breath sounds.

The laboratory analysis demonstrates a normal complete blood count with an erythrocyte sedimentation rate of 95 mm/h. The patient's liver function test results, renal function test results, electrocardiography findings, and chest x-ray findings are normal. His rheumatoid factor, antinuclear antibody, and extractable nuclear antigen profile are negative, and his hepatitis B and C and HIV serology are also nonreactive.

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Lumbar puncture for cerebrospinal fluid (CSF) analysis is performed, which reveals a protein level of 85 mg/dL, a white blood cell count of 40/mm3 with 55% neutrophils, and a normal glucose level. CSF Gram staining, acid-fast bacillus staining, CSF culture, CSF cytology, and oligoclonal bands are all negative.

Figure 8.

MRI of the brain with contrast reveals altered MR signals in the right optic nerve (Figures 5-7). The brain parenchyma is normal, with no demyelinating or mass lesion. MRI of the cervicothoracic spine with contrast is obtained and reveals patchy, abnormal MR signals extending from the level of the C2-C3 intervertebral disc to the T6-T7 intervertebral disc; this section of the spine shows low signal intensities on T1-weighted MRI scans, high intensities on T2-weighted MRI scans and fluid-attenuated inversion recovery (FLAIR) images, and inhomogeneous postcontrast enhancement (Figure 8).


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