I admitted this 25 yo single white man with a 1 month's history of gradual onset of dysarthria, diplopia and facial numbness. Past health includes controlled hypertension,non-smoker,non-drinker and no recreational drug use.No recent industrial exposure to possible toxins.He worked for a Hydro.Co. as a linesman. Neurological exam. showed R.INO,L.lower motor neuron VII, L.V and L.XII palsy. Normal mental status, motor and sensory exam.BP=130/85,P=70 reg. and afebrile.
Plain CT brain showed possible lesion of L.brain stem.Gad.MRI and MRA showed multiple lesions in L.frontal,temporal lobes and as well a large lesion involving L.pons and extending to midbrain and medulla.It did not enhance with Gadolinium. 2 follow MRI 2 weeks apart showed no significant change.MRI of spine showed no other lesions.CSF showed no cells,normal protein and glucose.Oligoclonal banding are negative. 4-vessels cerebro-angiogram showed no infarction,vasculitis, or AVM.
Routine blood work(including CBC,ESR,ANA & VDRL) + hypercoagulable state workup(Factor V Leiden,Protein C & S,Homocystine,Antiphospholipid antibody) all normal. HIV,Lyme,WNV antibodies are pending.
Now, what is your Dx?
What are your DDX??
How would you manage this case and why????
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(c) 2004 M.H. Rivner