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

• Non-smoker with sedentary lifestyle

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

.
• Hyperreflexia of DTRs of both U/E and L/E
• Bilateral Babinski present.
• 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.
• The patient has a positive Romberg's sign
therefore patient has mild ataxia.
• 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 ….?
• * 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).
• * MRI sagittal brain
section: shows
(multiple lesions
(arrows) that
radiates from the
surface of the lateral
ventricles).
• * 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.
• * MRI of the
patient’s spinal cord
(sagittal &
transverse
sections): shows
many white lesions
in some areas.
• 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.
? What is the Possible Diagnosis
Thank You