Clincal Presentation: Case History # 2 This is a 33 year old female who was well until 2 years ago when she noticed an onset of numbness in the left arm which was followed by subsequent numbness descending down to the left leg. She was able to walk normally but a few weeks later developed a relapse of neurologic dysfunction, particularly with both lower extremities. She was unable to walk for several weeks. At that time her family physician treated her with I. V. Solumedrol with excellent benefit, and the patient became ambulatory after 2 weeks. Over the next year, the patient had multiple relapses and remissions with episodes of upper extremity and lower extremity weakness, abnormal vision with blind spots, episodes of diplopia, typically a few days to three weeks. One of the attacks was rather serious with almost complete loss of ambulation.  (Q.1) The patient was treated with oral prednisone a number of times with very modest benefits from these treatments. One month ago a patient had a dramatic neurologic decline during which she was initially unable to sit up, lost strength and sensation in her lower extremities. There was a decrease in pinprick sensation to the level of T4-T5.   (Q.2) Patient's family reports that she had a lot of difficulty with mood control, particularly excessive crying and laughing.   (Q.3) Previous evaluations include MRI scan which is reportedly abnormal and CSF analysis which did show the presence of oligoclonal bands, a very high ratio of IgG to albumin, a markedly positive IgG synthesis at 59.0, and an elevated IgG index at 2.3 with the normal of 0.65. Family history is negative for any neurologic disorders, but positive for lung cancer and colon cancer. Medical illnesses: no major illnesses or surgeries. 2 pregnancies, resulting in C-section deliveries of two normal babies.   (Q.4) Neurologic Examination: Funduscopic examination reveals optic disk palor bilaterally. Pupillary responses are abnormal with RAPD detected on the left. Extraocular movements are full without nystagmus. However, there is a component of saccadic smooth pursuit. The remainder of the cranial nerve exam is normal. Motor examination is significant for paresis in the left upper extremity, particularly in the deltoid with the strength of 2/5   (Q.5) with remainder of musculature proximally being 3/5 and distally 4/5 in strength. Right upper extremity reveals normal strength throughout. The patient has paresis of the right lower extremity which is about 4/5, and in the left lower extremity which is 3+/5. Rapid alternating movements are decreased in all four extremities. Deep tendon reflexes are increased to +3 in the upper extremities, +4 at the knees, +4 at the ankles, and bilateral Babinski's signs are present. Sensory exam reveals mild vibratory sense loss in the distal upper extremities, but a very severe loss in the lower extremities: to the level of the knee on the left and mild to moderate loss to the level of the knee on the right. Position sense is disproportionately lost in both lower extremities to the level of the ankles.   (Q.6) The patient has a positive Romberg's sign and is mildly ataxic in tendon gait.  (Q.7)

	©   John W.Rose, M.D.,   Maria Houtchens, MSIII,   Sharon G. Lynch, M.D.