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Mr V.S. Mark Keezer R4 Neurology Case Presentation Feb 23, 2011

Mr V.S. Mark Keezer R4 Neurology Case Presentation Feb 23, 2011. ID 67 year old RHD retired salesman Presenting to Queen E clinic with subacute , progressive motor and sensory symptoms PMHx Non Hodgkin's lymphoma ( Dr Schustik , 2007) chemo q3wks X 1yr, last round 2008 Now in remission

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Mr V.S. Mark Keezer R4 Neurology Case Presentation Feb 23, 2011

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  1. Mr V.S.Mark KeezerR4 NeurologyCase PresentationFeb 23, 2011

  2. ID • 67 year old RHD retired salesman • Presenting to Queen E clinic with subacute, progressive motor and sensory symptoms • PMHx • Non Hodgkin's lymphoma (DrSchustik, 2007) • chemo q3wks X 1yr, last round 2008 • Now in remission • Melanoma (Dr Tremblay, 2010) • PET with hypermetabolic foci in right axillary LN, liver, spleen and possibly stomach • No treatment initiated yet.

  3. Medications • Gabapentin 600 mg potid • Atacand/HCTZ • Omeprazole • Habits • Remote smoker, occ ETOH • FHx • No Hx of neurological disease except for mother with PD.

  4. HPI • Starting in mid-November • Noted “prickling” in the toes of both feet • 1 wk later, noted similar feelings in both hands • Progressive ascension up legs and arms • Up to mid-thighs and mid forearms • “Prickling” replaced by lack of sensation.

  5. HPI • Early December • Tripping over carpets • Progression to a cane • Almost entirely bedbound for the last 4 days • Christmas • Decreased dexterity with a knife and fork • Now, cannot cut his own food as well as perpetually dropping objects, working harder to hold his coffee mug • No bulbar symptoms • No palpitations, abnormal sweating, incontinence, erectile dysfunction or early satiety • No back pain • No muscle twitches • No tremor.

  6. Physical examination • Supine BP 110/70, HR 100 • 2 mins standing BP 100/80, HR 108 • Cognition and language exam grossly normal.

  7. Physical examination • Cranial Nerves • No deficits • PERRLA 5 to 3 mm ou • No optic disc swelling • Motor • Atrophy of the deltoids, pectoralis, FDI, APB, IO and right gastrocnemius • Fasciculations of the FDI and gastrocs, but also pectoralis, APB and quadriceps • Pseudo-minipolymyoclonus • No pescavus or hammer toes.

  8. Physical examination • Motor • No tremor • No pronator dirft • NF 4/5, NE 5/5

  9. Physical examination • Sensory • Decreased pp in glove/stocking distribution • Vibration 1-2 Rydell score in ankles, 7-8 in DIP • No sensory level • Normal FN • Only able to stand briefly with locked/hyperextended knees. 0 0 R L 0 0 0 0 0 0 0 0

  10. Localization and approach to a differential • Suspected polyneuropathy • Hereditary • Acquired • Toxin/deficiency • Inflammatory • Metabolic • Infectious • What of the prickling? • What of the atrophy and fasciculations? • What of the frankly metastatic melanoma? • What of the prominent motor findings?

  11. Laboratory investigations • CBC • WBC 11.04 (neut 8.25) • Hgb 139 • Platelets 197 • Biochemistry • Na+ 134 • K+ 4.53 • Cl- 1054 • CO3 26 • Creat 82 • Urea 8.4 • Gluc 7.4 • Bilit tot 15.0 • ALT 93 • AlkPhos 86 • INR 1.01 • Anti Hu negative • VDRL negative • HIV negative • LDH 159 • SPEP normal • TSH 1.65 • Vit B12 191

  12. Laboratory investigations • CSF • WBC 30-35 (mononuclear) • RBC 0-2 • Protein 2.69 • Gluc 3.90 • Cult Neg • Right Axillary LN Bx • Metastatic melanoma • Spleen Bx • Most consistent with melanoma • CSF cytology • Rare lymphocytes • No neoplastic cells seen.

  13. MRI brain, C, T and L/S spine -/+ Gado • Right cerebellar tentorium • Enhancing 5.7cm dural based lesion • Enhancing lesions at C2, T9, L1, L2, L3, L5, S1 vertebral bodies and T12, L5 posterior elements • Suspicious enhancement of pre-cervical soft tissues and lung apices bilaterally • Enhancing lesion in the right iliac bone • Frank pathologic enhancement of the cauda equina • Possible pial enhancement along the thoracic cord • Impression: Metastatic disease +/- superimposed cauda equina enhancement • Leptomeningeal carcinomatosis vs CIDP.

  14. Electromyography • Sensory and mixed nerve conductions • Non-recordable median and ulnar studies • 30-80% decrease in sural amplitudes • 75% decrease in sural velocities • Motor conductions • 0-20% decreases in post tibital, median and ulnar amplitudes • 60% decreases in conduction velocity • 50% decreases in amplitude between distal and proximal sites • No evidence of temporal dispersion.

  15. Conclusion

  16. Course in hospital • Treated with IVIG and solumedrol qd X 5 days then qweek

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