A 25-Year-Old Man With Diplopia and Loss of Body Control

Sumaira Nabi, MBBS, FCPS; Shahzad Ahmed, MBBS; Fateen Rashid, MBBS; Mazhar Badshah, MBBS, FCPS

Disclosures

September 03, 2020

Physical Examination and Workup

Upon physical examination, the patient is an alert young man who is oriented to time, place, and person. His vital signs include an oral temperature of 98.6°F (37°C), a regular pulse of 70 beats/min, and a blood pressure of 120/70 mm Hg. His respiratory rate is 14 breaths/min. His Glasgow Coma Scale score is 15/15.

Upon ocular examination, the patient is unable to adduct the right eye when looking to the left (Figure 1). He also has nystagmus of the left eye with abduction. His eye movements are otherwise intact, and his gaze is conjugate when looking to the right. No lid swelling, ptosis, proptosis, or chemosis is noted. He also has left-sided relative afferent pupillary defect. Using measurement of meters (where 6/6 is the equivalent of the customary US units of 20/20), his visual acuity is 6/36 with his left eye and 6/18 with his right eye. Upon funduscopic examination, left optic disc pallor is noted (Figure 2). His cranial nerves are otherwise intact and symmetric. He has full symmetric strength with normal tone. He has no evidence of ataxia upon examination. Sensory examination findings are symmetric and intact. He has no signs suggestive of meningeal irritation.

Figure 1.

Figure 2.

The patient's abdomen is soft and nontender. No clinical evidence suggests organomegaly or ascites. His bowel sounds are audible. The precordial examination reveals normal heart sounds. Auscultation of the lung fields shows normal vesicular breathing.

Laboratory analysis reveals a complete blood cell count and erythrocyte sedimentation rate within the reference range. Liver and renal function test results, serum glucose levels, ECG findings, and chest radiography findings are unremarkable. The antinuclear antigen test results, extractable nuclear antigen profile, HIV serology, and hepatitis B and C test results are negative.

The patient's serum angiotensin-converting enzyme levels are normal. His cerebrospinal (CSF) fluid routine examination findings are normal; however, his CSF oligoclonal bands are positive. MRI of the brain with contrast shows a T2 fluid-attenuated inversion recovery high-signal area in the pons, in addition to other scattered white-matter hyperintensities (Figure 3). His visual evoked potential shows delayed P100, with abnormal waveform on the left side more than the right side (Figure 4).

Figure 3.

Figure 4.

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