Clinical Correlations
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Medical Grand Rounds
Clinical Vignette
October 1st, 2008
Jon-Emile Kenny M.D.
Chief Complaint
28 male presents with left lower
extremity weakness and parasthesias
for several weeks.
History of Present Illness
One year earlier, the patient had a similar
presentation. Work up at that time included an
MRI, which was unremarkable.
His current episode started several weeks ago
and is associated with an inability to walk and
impaired bladder and sexual function.
Furthermore, he has lost approximately 50 lbs
over the past year.
History
Past Medical History:
– Anterior and posterior uveitis
– Periodic oral ulcers
– Bilateral pyelonephritis 2005
Past Surgical History:
– none
History
Social Hx:
No toxic habits
Family Hx:
Non-contributory
Allergies:
No known drug allergies
Medications:
– none
Review of Systems:
– Exercise tolerance significantly reduced from his
baseline of 20 blocks and daily work-outs at the gym
– Remainder of review of systems negataive
Physical Exam
General: young male in no acute distress, sitting
comfortably, Alert and Oriented x3.
T:98.8oF BP:98/62 HR:88 RR:18 O2:99%RA
HEENT: multiple aphthous ulcers along edge of
tongue, no conjunctival injection.
Neuro: cranial nerves II-XII intact and symmetrical.
4/5 motor strength and 1+ reflexes in left lower
extremity. No saddle anesthesia.
The remainder of the physical exam was normal
Laboratory
WBC 12.9 mm3 (nl 4.5-11)
Hemoglobin 12.7 g/dL (13.5-16.5), MCV 89.9
Coagulation studies normal
Liver enzymes normal
Urinalysis negative
CSF: normal protein and glucose, WBC 7 (27%P,
67%L, 6%M), VDRL negative, IgG normal.
Imaging
Chest XR: normal
Brain MRI: Increased T2 signal of the thoracic
cord from T6-L1 with minimal enhancement and
cord expansion, smaller areas of increased
signal at C3/4 and T2-5. Lesions in the corpus
callosum and right internal capsule with
gadollinum enhancement.
Differential Diagnosis
Neuro-Behcet’s Disease
Multiple Sclerosis
Systemic Lupus Erythematosus
Neuro-Syphilis
Hospital Course
The patient had the following lab studies drawn:
–
–
–
–
–
–
–
–
–
–
ESR 24 (mild elevation)
RPR negative
ANA negative
lyme titers negative
SS-A/B negative
HTLV negative
ACE negative
ANCA negative
anti-cardiolipin negative
Hepatitis B/C negative
Hospital Course
The patient was started on a 5 day course of IV
solumedrol with a significant response; his
urinary symptoms and weakness resolved. His
course was uncomplicated and he was
discharged on a steroid taper.
Final Diagnoses
Neuro-Behcet’s Disease
Follow-up
Pt. has since had one recurrence of his
symptoms. He has responded well to inpatient
cyclophosphamide and colchicine maintenance
therapy.