Case Study 7 A 31-year-old woman is

Case Study 7 A 31-year-old woman is referred to a neurologist for evaluation of multiple neurologic complaints. She recalls a specific episode 3 years ago of mild weakness in her right leg, which seemed to resolve over time. Last month, she developed incoordination of her left leg and left hand, although these too seem to be improving. She feels that she has also become less steady on her feet over time. Though she always considered herself to be an energetic person, over the past year or two she has been constantly fatigued. She has also been having problems focusing her attention and feels that her thinking has slowed down in general. She has noticed that many of her symptoms sometimes get worse after a hot bath or after she has been to the gym. The patient recently was sick with the flu and is now suffering from a particularly bad exacerbation of her symptoms. Although her flu symptoms have subsided, she is concerned by the fact that 2 days following the onset of her flu she developed blurry vision in the right eye and pain in the eye associated with eye movements. On examination the patient is found to be afebrile and has normal vital signs. Her visual acuity in the right eye is 20/80 compared to 20/20 in the left eye. WBC, ESR, and C-reactive protein counts are all normal. CSF analysis reveals slightly elevated protein, with elevated immunoglobulin G and oligoclonal bands on further analysis. MRI of the brain is shown in the figure below. Questions What is the most likely diagnosis? What is the etiology of this condition? What are the clinical manifestations of this condition? Case Study 8 A 9-year-old boy is brought to the pediatrician’s office because his parents have become concerned about his unusual behavior over the past 2 days. The patient’s mother states that over the past 2 days her son has had several episodes of sudden alteration in behavior. He first complains of a rising feeling in his stomach and becomes fearful. He begins to have difficulty speaking, and then begins to stare and seems to lose awareness of what he is doing. He starts making strange lip-smacking movements, and assumes awkward postures with his right hand and arm. These episodes last about 30 seconds to 1 minute. As soon as an episode is over, the patient becomes tired and confused for a few minutes and does not seem to recall the event afterward. The patient is in good health, and all of his developmental milestones were normal. Obstetric history is unremarkable. He did, however, suffer from a prolonged episode of convulsions as a child in the setting of a febrile illness. On examination, the patient is well appearing. Height, weight, and head circumference are appropriate for his age. Physical examination reveals no rashes or other skin lesions. The patient is afebrile, and all vital signs are stable. Neurologic examination is normal, as is an MRI of the head. Electroencephalography (EEG) demonstrates left temporal slowing with occasional spikes and sharp waves. Questions What is the most likely diagnosis? What is the etiology of this condition? What are the clinical manifestations of this condition? Case Study 9 A 62-year-old woman is brought to the ED by EMS because she is experiencing weakness and language disturbances. She and her husband were having dinner when she suddenly stopped speaking, slumped to her right side, and slid to the floor. She was unable to get up off the floor because she could not move her right side. He also noted that that she neither spoke nor seemed to understand what he was saying. Approximately 45 minutes passed from the onset of symptoms to the time the patient was evaluated in the ED. Past medical history is significant for poorly controlled hypertension and stable angina. Her husband recalled that she had not taken her antihypertensive medication for several days. The patient smokes two packs of cigarettes per day. Family history is significant for hypertension and coronary artery disease. The patient’s father died at age 58 of a myocardial infarction. On physical examination, the patient is afebrile, has a blood pressure of 168/94 mm Hg, a heart rate of 70/min, and a respiratory rate of 18/min. Medications include acetylsalicylic acid (81 mg) and atenolol. A mental status examination reveals the patient to be globally aphasic. She cannot produce fluent speech, follow commands, repeat phrases, or name objects. Her gaze is deviated to the left. She does not blink to visual threat on the right side, and cranial nerve examination reveals a right-sided central pattern of facial weakness. Strength is 0/5 in the right upper extremity and 5/5 on the left. Strength is 0/5 in the right lower extremity and 5/5 on the left. In response to noxious sensory stimulation, she does not move her right side, but readily moves her left side with good strength. Laboratory examination including CBC and blood chemistries are within normal limits. Questions What is the most likely diagnosis? What is the etiology of this condition? What are the clinical manifestations of this condition?

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