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Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine. http://clinicalcorrelations.org. Medical Grand Rounds Clinical Vignette October 1st, 2008. Jon-Emile Kenny M.D. Chief Complaint.

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clinical correlations the nyu internal medicine blog a daily dose of medicine
Clinical Correlations The NYU Internal Medicine BlogA Daily Dose of Medicine

http://clinicalcorrelations.org

chief complaint
Chief Complaint

28 male presents with left lower extremity weakness and parasthesias for several weeks.

history of present illness
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
History
  • Past Medical History:
    • Anterior and posterior uveitis
    • Periodic oral ulcers
    • Bilateral pyelonephritis 2005
  • Past Surgical History:
    • none
history1
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
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
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
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
Differential Diagnosis

Neuro-Behcet’s Disease

Multiple Sclerosis

Systemic Lupus Erythematosus

Neuro-Syphilis

hospital course
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 course1
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
Final Diagnoses

Neuro-Behcet’s Disease

follow up
Follow-up

Pt. has since had one recurrence of his symptoms. He has responded well to inpatient cyclophosphamide and colchicine maintenance therapy.