45 year old female with depression and lower limb weakness

the complete case can be found here


A 45 year old female patient came to the OPD with the following complaints:
headache since the past 2 years
b/l lower limb weakness since 5 months 
h/o body pains, disturbed sleep, auditory hallucinations, double vision.

Diagnosed as depression without psychotic features.
Put on bulotin, ehisan’s plus for 1 week 

She had sudden fall- slurring of speech and  and swaying present.
Unable to get up from bed. Giddiness On lying down 

CT was done- showed small calcific foci in left high parietal region- Diagnosed as Ischemic stroke.

PAST HISTORY:
patient is a known case of hypothyroidism and is on Tab. Thyronorm since the past 4 months 
h/o uterine prolapse 20 yrs ago for which hysterectomy was done.



her 2nd child died at 1 month of age due to unknown reasons
her 3rd child died  at age 23 due to kidney
these could be reasons for her depression

medications taken by patient
  1. Nortryptiline
  2. Cerebroprotein
  3. MVT
  4. Ecosprin
  5. Clopitab
  6. Atovastatin
  7. NSAIDS

EXAMINATION:

Patient conscious, coherent, cooperative.

On CNS EXAMINATION:

Higher mental function- normal 
Oriented to time place and person 
Cranial nerves- 3rd and 6th CN affected 
                         7th cranial nerve on affected on left side 

Motor system:

Hypotonia in right upper and lower limb
Reflexes-Superficial reflex:
                 Abdominal reflex absent 
                 Plantar Extensor reflex present 
                Deep reflex: exaggerated    
Gait- ataxic
Sensory system- Normal
No meningeal signs 

INVESTIGATIONS:

•Hb- 11.4 gm/dl
•ECG
•MRI  plains and contrast with angiogram- patchy hyperintensities on both cerebral hemispheres.
MR angiography: hypoplastic basilar-vertebral arteries 
•Carotid Doppler - soft plaque in left carotid bifurcation causing no significant stenosis

A= hyperintensity at thalamus region





MY DEFFERNTIAL DIAGNOSIS FOR THIS CASE ARE

Neuro Behçet’s disease
devec's disease
Vasculitis
Nuerosarcoidosis


diagnosis of neuro-behcets' disease

 "The international Study Group for BD criteria [] for diagnosis requires satisfaction of two of the following four criteria ‘in the presence of recurrent oral ulcerations’: (i) recurrent painful genital ulcers that heal with scarring, (ii) ophthalmic lesions such as anterior or posterior uveitis, hypopyon or retinal vasculitis, (iii) skin lesions such as erythema nodosum such as lesions, pseudofolliculitis, papulopustular lesions or acneiform nodules and (iv) positive pathergy skin test."



Diagnosis of multiple sclerosis

this is the recent change in diagnostic criteriea 
" One major change is the inclusion of cerebrospinal fluid (CSF) oligoclonal bands as evidence of dissemination in time in a patient with dissemination in space gathered by clinical or magnetic resonance examination. "



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