Multiple Sclerosis

Case #340: MRI Brain, 6/21/94 &12/9/94: Multiple Sclerosis(MS).

UIHC:9417331-0

DOB: 6/20/1967

IN:SH

DOE: 12/7/94

CC: Dysarthria.

Hx: This 27y/o RHF with a h/o of MS presented on 12/7/94 with a one month history of progressive generalized numbness(strange feeling; not sensory loss), difficulty with gait, dysarthria, left facial weakness, lethargy and dysphagia. She denied any recent viral illness. However, on the day of admission she began feeling nauseated, but denied fever, chills or vomiting.

Her history of demyelinating disease dates back to 3/94 when she had an episode of nausea, vomiting, lethargy, dysarthria and generalized weakness. She diagnosed with gastroenteritis by her local physician. However, her weakness remained unexplained. On 6/18/94 she was admitted to a local hospital for 2 days of nausea, vomiting, difficulty with gait and facial numbness. Workup at that time included a normal GS, CBC, ANA, RPR, NH3, HIV titer, Lyme titer, and TFT's. 2 separate CT scans of the brain with and without contrast revealed nonspecific perventricular white matter changes. THe patient left the hospital AMA and went to another hospital. At the second hospital, a lumbar puncture was unsuccessfully performed and she was transferred to UIHC on 6/20/94. While at UIHC she complained of nausea, vomiting, slurred speech, lethargy, genelarized body numbness and weakness, blurred vision and diplopia. 6/21/94 MRI brain scan revealed multiple foci of increased signal in the periventricular white matter on T2 weighted images suggestive of demylination. Lumbar puncture, 6/21/94, revealed CSF: Protein 49(normal,45), Glucose 71, WBC 8(7lymphocytes, 1 Histiocyte), RBC 2, Albumin 21.7(normal 14-20), IgG 12.0(normal<6.2), IgG index 1.5(normal<0.7), Oligoclonal bands were present. She then received a 5 day course of IV Solu-Medrol followed by a Prednisone taper. Her difficulties with vision resolved one month after treatment.

She did well, except for an occasional mild headache, until one month ago--as described above.

MEDS: Propranolol 60mgqd for headaches, Naprosyn, Zantac.

PMH: as above; and including "migraine" headaches.

FHx: noncontributory.

SHx: Single, lives with boyfriend, no children, denies ETOH or illicti drug use, and admit to smoking 1/4 packs of cigarettes per day.

EXAM: BP132/73 HR79 RR16 36.2

MS: A&O to person, place and time. Mild dysarthria. Slightly depressed mood with flattened affect.

CN: Pupils 3/3 decreasing to 2/2 on exposure to light. No RAPD noted. There was left upper and lower facial weakness with no sensory loss to PP testing. Shoulder shrug was slightly decreased on the left. No Lhermittes sign was induced.

Motor: 5/4 throughout BUE. 5/5- throughout BLE.

Sensory: unremarkable.

Coord: slowed RAM, FNF and HNS movements on the left.

Station: No pronator drift, truncal ataxia, or Romberg sign.

Gait: mildly hemiparetic on left.

Reflexes: 3/3 throughout BUE. 2/2 throughout BLE. Plantar responses were withdrawn on the right and extensor on the left.

Gen Exam: unremarkable.

COURSE: Urinalysis, CBC, GS were unremarkable. She was given a 5 day course of Solu-Medrol 250mg IV q6hours followed by a Prednisone taper. She was placed on Paxil for depression. MRI Brain, 12/9/94, revealed new and old areas of increased signal on T2 weighted images in the periventricular white matter regions and right pons. She was discharged home and had reported no further episodes up to 5/97.