GRAND ROUND

PRESENTATION
PRESENTERS:
DR. EFFESO KAGUO
DR. SHANEABBAS MOHAMED
DR. AHLAM MATTAR

DATE: 16th MAY 2023

Patient Particulars
• Name: G.B.M
• Age: 38 years
• Sex: Male
• Residence: Morogoro
• Occupation: Watch guard
• Education: Form four graduate
• Ethnicity: Black
• Insurance: NHIF
• Informant: Patient
• Referred from Morogoro Regional Referral Hospital
Chief complaints
• Upper and Lower limb weakness for 14 months
• Loss of vision for 2 months
History of Presenting Illness
Upper and lower limb weakness for 14 months

• The patient was well until march of last year

• Gradual onset, progressively increasing in severity
• Initially started as numbness on the right lower limb and 2 weeks later was followed
by weakness on the same limb
• It was during this time also when he noted he couldn’t walk with the same pace as he
used to
• 1 month later, it progressed to involve the right upper limb. During this time the
patient could walk with support
• 2 months since onset, weakness progressed to involve the left LL and UL
History of Presenting Illness
• At this time, the patient could still walk with support and could untie his shirt and comb
his hair with difficulties

• Weakness was persistent ,with no periods of remission or exacerbation over course of the
day

• Four months after onset of symptoms the patient couldn’t be able to walk even with
support

• He has been bed ridden bound for the past 8 months

• No identifiable relieving or exacerbating factors

History of Presenting Illness
• It was associated with
• Painful muscle spasms occurring periodically with no specific periodicity involving
mainly the extremities and abdominal muscles
• Constipation

• It was not associated with

• Loss of sensation
• Urinary incontinence or retention
• Headache, convulsions, altered mental status or LOC
• Nausea, vomiting or hiccups
• Difficult speaking, swallowing or breathing
• No drooping of the eye lids
History of Presenting Illness
• No history of
• Fever or excessive night sweats
• Respiratory or diarrhoea illness prior to onset of symptoms
• Trauma
• Skin lesions or joint pain/swelling
• Dry mouth, dry eyes, dry cough, itchy skin, swellings on the face, neck or under
armpits
• Anterior neck swelling
• Dark coloured urine
• Excessive daytime sleepiness or narcolepsy
• DM or HTN
• Similar disease in his family on both maternal or paternal side
• Being treated for malignancy
History of Presenting Illness
Loss of vision for 2 months

• Gradual on onset
• Started as blurring of vision on the left eye and later on involved both
eyes within 2 days
• Progressed to complete visual loss within one week
• It was associated with frontal headache, eye pain described as dull
aching within the eyes worsened by eye movement
• No eye discharge or tearing, redness or itching
 Course of Illness
• At onset of symptoms patient (Rt upper and lowerlimb weakness)
attended at MRRH and was referred to MNH

• Was admitted for two days and was discharged with a diagnosis of
stroke. No imaging was done.Discharged with atorvastatin 20mg od and
Nat B

• He has been at home since discharge attending clinic at Morogoro

hospital, and doing physiotherapy and was on Nat B and pregabalin
75mg with no improvement

• He was referred again this time after vision disturbance/loss

Review of other systems
• ENT – no ear pain or discharge, no nasal discharge.
• CVS - No DIB on lying flat, air hunger at night or LL swelling
• Haematological- No history of BT or bone pain
• GUS - No history of decreased urine output, blood in urine or
increased urinary frequency
Past medical history
• 2nd admission
• No prior history of surgery
• No history of any chronic medication
• Not known to be allergic to any food or drugs
Family Tree
Family and Social history
• Form four graduate currently working as a watch guard
• Has history of alcohol intake (local breweries including gongo) for the
past 15 years. Stopped after becoming sick
• No hx of smoking
Dietary history
• Not vegetarian not on any food restriction
• No change in food intake after illness
• Three meals per day
• Breakfast: tea with chapati
• Lunch: ugali/rice and meat and fish
• Dinner: ugali/rice with beans/meat occasionally vegetable
• Water: approximately 1.5L day
• Fruits: On alternate day mainly in the form of fresh juice

Conclusion: Adequate quantity and quality

Summary 1
• G. B. M 38 yrs male, presented with persistent and progressive weakness
of all limbs for 14months , associated with numbness and painful
paroxysmal tonic spasms of the trunk and extremities. No bulbar or
respiratory muscle involvement. With 2 months h/o of bilateral visual loss
associated with eye pain worsened by ocular movement
• No h/o headache, convulsion, vomiting or hiccups, constitutional
symptoms trauma or respiratory/diarrhoea illness prior to onset of
symptoms
• Has negative family h/o of similar illness
General Examination
• Fully Conscious, normal hair texture • No palpable lymph nodes
and distribution • Normal skin and appendages
• Afebrile • No lower limb pitting edema
• Not Pale
• No Angular stomatitis
• Not Jaundiced
• Normal Nasal cavities
• Normal oral pharynx
• No anterior neck swelling
• No Asterixis
• No fine tremors
Vital Signs
• SpO2 = 99% on room air
• Pulse Rate = 74bpm
• Respiratory Rate = 17 breaths/min
• Blood Pressure = left upper limb - 122/72 mmHg
• Temperature = 36.8°C
• RBG = 5.3 mmol/L

CONCLUSION: Normal general examination and vital signs

 Eye Examination
• No ptosis, exophthalmos
• Normal Eye lids, normal eye rashes alignment,
• Conjunctiva translucent
• Cornea transparent,
• Anterior chamber-normal with clear aqueous humor
• Iris-brownish
• Lens-is transparent
Nervous System Examination
Higher Cerebral Functions
• Conscious
• Oriented to TPP
• Normal speech and language
• Normal short and long term memory
• Normal insight and judgment

Conclusion: Normal Higher Cerebral Functions

 Mini Mental Status Examination
PARAMETER SCORE
ORIENTATION 10/10
REGISTRATION 3/3
ATTENTION AND CALCULATION 5/5
RECALL 3/3
LANGUAGE
NAMING 2/2
REPEAT PHRASE 1/1
THREE STAGE COMMAND 3/3
OBEY WRITTEN INSTRUCTION Not assessed because of poor vision
WRITE A SENTENCE Not assessed because of weakness
COPYING Not assessed because of weakness
TOTAL 27/30

Conclusion - Normal Higher Cerebral Functions

Nervous System Examination

Signs of meningeal irritation

• Neck was soft
• Negative Brudzinski sign
• Negative Kernig’s sign

Conclusion: No signs of meningeal irritation

Cranial Nerves
• CN I: Can smell normally
• CN II:
• Visual fields - complete blindness on all fields
• Visual acuity - No perception of light on both eyes
• Visual color could not be assessible
• Pupils - dilated bilaterally 3 - 4mm in size and not reacting to light. No
consensual response.
Fundoscopy

• Disc was pink with generalised pallor

• Slightly dull fovea reflex
• Cup disk ratio: 0.4mm
• Normal distribution of retinal vessels
• No exudates on the peri-retinal area
• Normal macula
Cranial Nerves
• CN III,IV,VI:
• Inspection- No ptosis
• Eye movement- can move eyes in all directions

• CN V:
• Can clench teeth, normal facial sensation (V1,V2,V3)

• CN VII:
• Can Close Eyes Against Resistance, Symmetrical Face
Cranial Nerves
• CN VIII:
• Can Hear

• CN IX, X:
• No Uvula Deviation and gag reflex present
• CN XI:
• Can Raise Shoulders against resistance
• CN XII:
• Can Protrude tongue, no fasciculation or atrophy Of the tongue

Conclusion: Bilateral Optic nerves lesion

Motor And Reflex Examination
UPPER LIMBS RIGHT LEFT

BULKINESS REDUCED REDUCED

TONE INCREASED (SPASTIC) INCREASED (SPASTIC)

FASCULATIONS NO NO

POWER 4/5 ON ALL MUSCLE GROUPS 4/5 ALL MUSCLE GROUPS

REFLEX /DTRs BRISK 3+ BRISK 3+

Motor and Reflex Examination
LOWER LIMB RIGHT LEFT

BULKINESS REDUCED REDUCED

TONE INCREASED (SPASTIC) INCREASED (SPASTIC)

POWER 3/5 ALL MUSCLE GROUPS 3/5 ALL MUSCLE GROUPS

FASCICULATIONS NO NO

TENDON REFLEX/DTR ↑ ↑ WITH CLONUS (4+) ↑ ↑ WITH CLONUS (4+)

PLANTAR REFLEX POSITIVE POSITIVE

JAW REFLEX NORMAL NORMAL

CONCLUSION-spastic quadriparesis with hyperreflexia and normal jaw reflex, positive

plantar reflex = UMN signs localising to high cervical spine
Clonus Periodic spasms
Sensory Examination
RIGHT LEFT
JOINT POSITION NORMAL NORMAL
VIBRATION NORMAL NORMAL
PIN PRICK NORMAL NORMAL
TEMPERATURE NORMAL NORMAL

LIGHT TOUCH NORMAL NORMAL

Conclusion : NORMAL SENSATION

Coordination
• Finger to nose test: not done (vision)
• Heel - Shin test: not done (weakness)
• Romberg test: not done (weakness)
Musculoskeletal System
GAIT: not assessed

ARMS: no joint deformity, no arm muscle wasting, no tenderness, normal

range of movement in all joints

LEGS: no deformity, no muscle wasting , no swelling, no abnormal

shortening, normal joint movement, no joint tenderness and no
subcutaneous nodules

SPINE: No deformity, No point of tenderness

Conclusion: Normal MSS

Cardiovascular Examination
• Pulse rate 74 beat/min
• Regular radial pulse, good volume, not collapsing synchronised with
brachial, femoral, popliteal, posterior tibia and dorsalis pedis pulse
• No raised jugular venous pressure
• No carotid bruits
• No precordial hyperactivity
• No parasternal thrill
• No heaves
• Apex beat at 5th intercostal space midclavicular line
• 1st heart sound and 2nd heart sound heard. No added sounds
Conclusion - Normal Cardiovascular examination
Abdominal Examination
• Normal abdominal contour, moves with respiration
• Umbilicus inverted and centrally located
• No visible veins, scars,
• Soft, tenderness
• Liver span – 14 cm
• Spleen - not palpable
• Kidneys not bi-manually palpable
• Tympanic percussion note
• Normal Bowel Sounds Heard, no renal bruits
• Normal external male genitalia, normal DRE findings
Conclusion: Normal abdominal findings
Respiratory Examination
• Respiratory rate 17 breath/min
• No chest deformity
• No scar
• Normal chest movement
• Trachea centrally located
• Resonant note on percussion bilaterally on both anterior and posterior aspect
of the chest.
• Normal vesicular breath sound bilaterally and on both anterior and posterior
aspect of the chest
• Normal vocal fremitus
CONCLUSION- Normal respiratory examination
Summary 2
• G. B. M 38 yrs male, presented with persistent and progressive weakness of
all limbs for 14months , associated with numbness and painful paroxysmal
tonic spasms of the trunk and extremities and bilateral visual loss for 2
months associated with eye pain aggravated by ocular movement.
• No h/o headache, convulsion, vomiting or hiccups.
• No hx of constitutional symptoms, trauma or respiratory/diarrhoea illness
prior to onset of symptoms,
• Has negative family h/o of similar illness
• Examination revealed bilateral optic nerve lesion with total blindness and
upper motor neuron signs localizing to the upper cervical spine manifesting
as spastic quadriparesis with brisk tendon reflexes but with intact sensations
DIAGNOSTIC FORMULATION AND
INVESTIGATIONS
Problem list
• Bilateral Upper and lower limb weakness
• Bilateral loss of vision
• Painful muscle spasms
• Spastic quadriplegia
• Hyperreflexia
• Bilateral optic nerve lesion
PROVISIONAL DIAGNOSIS
• Subacute transverse myelitis with optic neuropathy
• Neuromyelitis Optica Spectrum disorders (NMOSD)

Differential diagnosis
• Multiple Sclerosis
• Myelin Oligodendrocyte Glycoprotein Antibody - Associated
Disease (MOGAD)
NMOSD

POSTIVE NEGATIVE

• Age (30 - 40) • Male sex ( F:M - 9:1)

• Race (African) • Monophasic - progressive nature
• Features of optic nerve neuritis of symptoms
• Features of myelitis • Insidious onset of weakness
• Painful spasms
Multiple Sclerosis

POSTIVE NEGATIVES
• Optic involvement • No features of cortical or brain
• UMN signs stem involvement
INVESTIGATIONS
Total spine MRI
Brain MRI
CSF analysis
Visual Evoked Potential
Thyroid Function Tests
TEST RESULT REFERENCE
RANGE
TSH 0.6094 0.49 – 4.67

FREE T3 2.16 1.45 – 3.48

FREE T4 1.10 0.71 – 1.85

Full blood picture
TEST RESULTS NORMAL RANGE
WBC 4.8 4 - 10
NEUT 2.7 2 – 6.9
LYM 1.2 0.6 – 2.4
MONO 0.3 0 – 0.9
ESO 0.4 0 – 0.7
RBC 4.53 4.5 – 5.5
HGB 14.4 13 – 17
MCV 92.1 92.1
MCH 31.8
MCHC 34.5
PLT 265
 Inflammatory markers
18/9/22 5/10/22 12/10/22

C – REACTIVE Not done 31 40

PROTEIN
ESR 18 Not done 29

Serum ADA 10
Serum Electrolytes and Renal Function test
TEST RESULTS

Sodium 138 135 - 145

Potassium 4.5

Chloride 101

Creatinine 66 63.6 - 110

BUN 3.2 3.2 – 7.4

eGFR 117ml/min/1.73m2
Sodium- 138 RBG- 5.3mmol/l
Potassium- 4.17 HBA1C 5.8%
Calcium- 2.11 (1.9-
T3-2.16 (1.4- )
T4- 1.1 (0.7- )
TSH- 0.6 (0.4- )
Creatinine 66 (50- 120mmol/L)
BUN- 3.2 mmol/L (2.1-8.5)
Creatinine kinase 150 (55-190u/l)
AST-
ALT
Autoimmune markers
MARKER RESULT
ANA NEGATIVE

ANCA C NEGATIVE

ANCA P NEGATIVE

RHEUMATOID FACTOR NEGATIVE

Haematology
• WBC- 4.6 • Vitamin B-12 - 1912 (187-
• ABS NEUTROPHIL 2.7 • Folate -
• HB- 14.4
• HCT- 41.7
• MCV- 92
• PLATELET- 265

• NORMAL FBC
Serology

HIV NEGATIVE

VDRL NEGATIVE

HBsAg NEGATIVE

HepCAb NEGATIVE
URINALYSIS
• Dipstick Microscopy
Colour- normal White blood cell- negative
Ph- 6.7 Red blood cells- negative
Specific gravity- 1.02
Epithelia cells- negative
Glucose- negative
Ketone- negative
Protein- negative Conclusion- Normal urinalysis
Urobilinogen-negative
Leucocytes- negative
Nitrite- negative
WISH LIST
• Aquaporin-4 (AQP4-IgG) antibodies test
International consensus diagnostic Criteria for NMO
1. Criteria for NMOSD with AQP4-IgG
• One or more of the six core clinical characteristics
• Positive serum test for AQP4-IgG with the use of the best available detection
method (cell-based assay strongly recommended)
• No alternative diagnoses
2. Criteria for NMOSD without AQP4-IgG or with unknown antibody status
• Two or more of the six core clinical characteristics; must include at least
one of the following three core clinical characteristics:
• Acute optic neuritis with either no abnormalities or only nonspecific white-
matter lesions in the brain on MRI, or with orbital MRI showing a lesion
extending over more than half the optic-nerve length or involving the optic
chiasm
• Acute myelitis with a longitudinally extensive cord lesion on MRI
• Area postrema syndrome with a dorsal medullary lesion on MRI
• Negative test (or tests) for AQP4-IgG
Final diagnosis
• NEUROMYELITIS OPTICA
DISCUSSION
NMO (neuromyelitis optica)
Management of the patient
Progress
Why this case
• Rare case
• Stroke in young adult without risk factors?? - need thorough
evaluation!
• Diagnostic challenges
Acknowledgement
• Dr. Kimambo - Neurophyscian
• Dr.Mohamed Manji
• Dr. Brighton
• Dr. Zuwena- Radiologist (MNH - Mloganzila)
• Dr. Hyera
• Fellow residents