A 24 year-old woman was admitted to the a psychiatric ward with a 2 week history of thought disorder. She had become suspicious of her family, thinking they were trying to poison her. On admission her neurological examination was otherwise normal. There is no relevant family history except for an episode of depression while she was at University.

She was treated with antipsychotic agents with some response but then developed a generalised tonic-clonic seizure. Ten hours after the seizure she is confused, sweaty and tachycardic (HR 130). She exhibits waxy flexibility, a staring expression and adopts a dystonic posture of her left arm.

How would you proceed further?

Thanks to Dr David Hunt again for this week’s case.

A 42 year-old man presents to his neurologist with a 8 month history of progressive weakness of the right hand.

He is otherwise well with no family history of neurological disease.

Systemic examination reveals mild gynaecomastia but is otherwise normal.

Neurological examination shows wasting of the interossei with 3/5 weakness in finer abduction and adduction. Abductor pollicis brevis is also slightly weak.

Sensory examination is normal and reflexes are reduced in the right arm. Legs and cranial nerves are normal.

How would you approach this clinical problem?

Thanks again to Dr David Hunt for this case.

A 65 year-old man presents with a 6 week history of memory loss which has got progressively worse. His wife has noticed that he has had a couple of episodes where he has been vacant and his face has grimaced and his arm shook.

He is otherwise well with no significant family history. He was seen by the neurology team who performed an Addenbrooke’s Cognitive Examination, and he scored 86/100. The examination was otherwise normal. Blood tests showed a mild hyponatraemia. A head CT scan is performed, which is normal.

What is the differential diagnosis?

There will be a mid-week case update with more clinical information for all IM students. Thanks to Dr David Hunt, Clinical Lecturer in Neurology, for the case and for moderating this week’s discussion.

A 41 year old woman presents to the emergency department with a 1 day history of rapidly progressive symmetrical weakness and numbness affecting all 4 limbs. She first noticed numbness and tingling in her hands which spread into the legs over a matter of hours. There is both urinary and faecal incontinence. She is otherwise well except for an episode of optic neuritis 3 years previously which led to a complete loss of vision in her right eye, with only mild degree of recovery.

On Examination:
Cranial nerves – right relative afferent pupillary defect with a dense centrocecal scotoma.
Upper Limbs: 3/5 symmetrical pyramidal weakness with brisk reflexes.
Lower Limbs: 3/5 symmetrical pyramidal weakness with brisk reflexes and upgoing plantars.
There is a sensory level at C5/6.

Systemic examination – Hypertensive 180/120, apyrexial, otherwise normal.

• What is the most likely diagnosis and the differential diagnosis?
• What investigations are needed?
• What immediate steps in management are needed?

Many thanks to Dr David Hunt, Clinical Lecturer in Neurology at the Univeraity of Edinburgh, for this case. Dr Hunt will be leading the discussion in the classroom. Students be sure to add your thoughts.

A 31 year old woman is seen by you in the neurology clinic. She was referred by the ophthalmology team, following a presentation with an isolated episode of left-sided optic neuritis which has fully resolved. They arranged a routine MRI scan of the brain which was reported last week showing ‘multiple white matter lesions in a periventricular distribution, consistent with a diagnosis of multiple sclerosis’. She is unaware of the MRI report but the ophthalmology team have told her that the MRI scan was performed ‘to look for multiple sclerosis’.

She comes to the clinic to discuss the findings.

How would you approach the consultation?

Thanks to Dr David Hunt for this week’s case. He’ll be moderating the discussion in the classroom.

A 22-year-old right-handed man presents to the emergency department with a two-week history of worsening persistent headache after returning from a summer holiday in Spain.

He describes the headache as generalised, severity 7/10, worse on coughing and on waking. It is partially alleviated by upright posture, and by regular paracetamol. He feels occasionally nauseated, but has not vomited. He describes a ‘whooshing’ pulsatile sound in his left ear, which is worse at night.

Other than the regular paracetamol, he takes neither regular medication nor recreational drugs. He drunk alcohol to excess on the holiday and is a social smoker.  The only family history of note is that his father suffered an ischaemic stroke at 40 years old.

On examination he is apyrexial. Cranial nerve examination reveals a small central area of visual loss in the left visual field, but normal visual acuity and pupillary reflexes bilaterally. Fundoscopy reveals bilateral papilloedema. The rest of his neurological examination is normal.

• What is the mechanism of development of papilloedema?
• What do you think is the possible aetiology in this case, and what are the differential diagnoses?
• What would your first investigation(s) be?

Thanks to Dr Russell Hewett for this week’s case. Dr Hewett will be moderating the discussion in the classrooms this week.

A 34 year old right handed supermarket employee complains of a two week history of intermittent blurriness of her vision especially when driving or watching TV. She has been finding it more difficult to stack the higher shelves at her work and occasionally feels breathless. Her husband has noticed a slight droopiness of her left eye towards the end of the day. She also complains of two day history of ‘a numb face’ and intermittent speech difficulty. She takes levothyroxine for hypothyroidism. There is no family history of note.

Cranial nerve examination reveals normal visual acuity, visual fields, pupillary reflex and fundoscopy. Eye movements are apparently normal, though she develops diplopia on left horizontal and up gaze. There is a very slight ptosis of the left eyelid. Sensation of the face is normal. Speech is normal though she has a flattened smile, and is unable to whistle. Jaw jerk is present. Limb examination reveals mild bilateral shoulder abduction weakness. Deep tendon reflexes are present and symmetrical.

Routine observations and blood tests including ESR and CK are normal. TFT’s demonstrate adequately treated hypothyroidism. ECG and CXR normal.

• What is the likely diagnosis?
• Is there anything else you would like to perform during examination?
• What other investigations would you like to request?

Thanks to Dr Russell Hewett for this case and for moderating the discussion in the classroom. If you want to find out the answers, click below.

A 45 year old man presents with a weak left foot. The day prior to presentation he developed a deep burning pain in the foot. On waking he finds that his foot is weak and he has a tendency to trip over it when walking.

On questioning, he reveals that for the last 3 months he has developed an ache in his left hand associated with mild weakness of grip and numbness over the ulnar border of the forearm.  He has lost 1 stone in weight over a similar time-period and describes occasional night sweats. There are no sphincter symptoms.

Admission examination reveals normal cardiovascular, respiratory and GI systems. Cranial nerve examination is normal. There is wasting of the intrinsic muscles of his left hand but with a preserved thenar eminence. He has a weak right thumb (in abduction) but normal right hand strength otherwise. There is patchy sensory loss in the left ulnar border of the forearm.  Upper limb reflexes are normal. There is evidence of a small digital infarct on one of his toes. In the lower limbs he has a pronounced left foot drop with 1/5 in ankle dorsiflexion and 3/5 power in ankle eversion and plantarflexion. There is sensory loss over the dorsum of the left foot. His left ankle jerk is reduced.

Investigations show raised platelets (610 x 10⁹ /l) but otherwise normal FBC, renal function, liver function tests and bone profile. ESR (erythrocyte sedimentation rate) is 75mm/hr, and CRP (C-reactive protein) is 20mg/l.

What is the differential diagnosis, the most likely diagnosis and investigation of choice?

MSc students please add you thoughts and comments to the class discussion board.

Thanks to Dr David Hunt for this case.

A 28 year-old man presents to the emergency department with difficulty walking. Two days previously he noticed tingling in his hands then subsequently both feet. He then experienced severe midthoracic back pain. Over the next day he developed proximal leg weakness and a loss of balance precipitating admission to hospital. Sphincters are not affected. He is otherwise well and is recovering from an upper respiratory tract infection.

On admission he is apyrexial. Cranial nerve examination reveals mild bifacial weakness and a mild dysarthria. In the upper limbs, sensation is normal and there is pseudoathetosis. Strength is normal. Both biceps reflexes are present with reinforcement but otherwise reflexes are absent. In the lower limbs he can barely stand unaided and Romberg’s test is strongly positive. There is proximal weakness. He is arreflexic.

Lumbar puncture is acellular with a raised protein at 1.3g/L and a normal paired glucose. ECG shows marked sinus arrhythmia. Nerve conduction studies are normal.

1. What is the diagnosis?
2. Are any more investigations required?
3. What are the principles of management?

Answer below.  Thanks to Dr David Hunt for this case.