Most likely diagnosis ?

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Most likely diagnosis ?

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13 Posts

DrAlex_76
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07/10/08 - 07:29 PM

29 yo woman presents with paraplegia, urinary incontinence urgency. Neurologic examination shows spasticity, hyperreflexia in lower extremities and impaired vibration + proprioception of her left arm. What is the most likely diagnosis ?

Eagle_303
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07/10/08 - 09:01 PM

combination of

Posterior column signs = impaired proprioception and vibration
UMN signs = hyper-reflexia in lower limbs + spasticity

reminds of Sub-acute combined degenration :

Look for

B12 def i.e megaloblastic anemia and MMA-uria ,homocysteinemia if the patient is HIV -tive.

If HIV + tive it will be Vacuolar myelopathy

WaqasQureshi
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07/11/08 - 12:33 AM

you are right my friend that it can be all the things you told but MS is the most likely diagnosis with this presentation.

Plus the nutritional and metabolic defects are usually symmetrical. There is asymmetry in left arm. So for board purposes, this should be MS

WaqasQureshi
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07/11/08 - 12:34 AM

vacuolar myelopathy has a very low incident plus it is kind of diagnosis of exclusion.

Eagle_303
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07/11/08 - 03:10 AM

You might be absolutely true but Unless you have H/O repeated attacks separated in time and severity ,to say MS is difficult. Scenario might be having something extra which the poster is missing in the question.

Scanning speech
Intentional tremors
Nystagmous
Optic neuritis

It is difficult for me to look for it .

Eagle_303
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07/11/08 - 03:29 AM

WaqasQureshi wrote:
.

Plus the nutritional and metabolic defects are usually symmetrical. .

Can we assume if the III cranial N palsy occurs in DM so it should be bilateral because it is a metabolic disorder.

""So for board purposes, this should be MS ""

Current medical diagnosis and treatment says: about MS

"The diagnosis cannot be made with confidence unless the total clinical picture indicates involvement of different parts of the central nervous system at different times. "

Best of luck

DrAlex_76
Forum Guru

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07/11/08 - 08:19 AM

the answer is MS , we will look for oligoclonal bands in CSF. More things to expect are bilateral trigeminal neuralgia, internuclear ophthalmolplegia. This is real tough for the board if they just give the above scenario. Thanks !

tompat
Forum Elite

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07/12/08 - 02:41 PM

to eagle:
to say that III nerve palsy should be bilateral in DM on similar basis as nutritional disorders showing symmetrical involvement is WRONG.
in DM , III nerve palsy is due to vascular involvement and vascular dynamics/ pathologies aint symmetrical in body.

WaqasQureshi
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07/25/08 - 05:38 PM

yeah tompat grin

true! that isnt metabolic

Eagle_303
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07/26/08 - 07:19 AM

#10

WaqasQureshi wrote:
yeah tompat grin

true! that isnt metabolic

You want to say that DM is not a metabolic disorder ?

pipi99
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07/28/08 - 11:50 AM

#11

No, he said this "in DM , III nerve palsy is due to vascular involvement "

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DrVirgo
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07/28/08 - 12:57 PM

#12

Patchy neuro defiecits separated by space and time(?) = MS

If it were B12 subacute combined def, i believe the question would have to give some more info on nutrition, like not eaten animal products for years or something like that plus some hematologic stuff like high MCV, etc.

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tilingo
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07/28/08 - 01:23 PM

#13

in real life.. it could be ANYTHING!!!!

for boards... MS maybe.. hehe

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