| QUIZ: Inch by inch, it's a cinch |
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| Friday, 09 December 2011 14:30 |
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Case description: Mrs. XY is a Caucasian 22 yo female that sees double when looking to the right. She says that this appeared 2 days ago. At first she attributed it to tiredness but as the symptom insisted she finally decided to visit a GP. She additionally mentions that for the last 3 months she suffers from haedaches and pains in the joints and muscles, has a poor appetite and feels tired most of the time. Her physical as well as the neurological examination were normal with one exception. Upon examination of the extra-ocular movements and as the patient was looking to the right, the left eye didn't seem to move at all, while the right was fully adducted with simultaneous nystagmus. Question: What is the differential diagnosis?
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Comments
It could also be a paralysis of the left m. rectus medialis, but the nystagmus makes an INO more likely.
As for the headache, muscle and joint pains, poor apetite and tiredness. There is a wide array of possibilities here. Could be MS (but joint aches?), could be auto-immune, could be infection.
Though these symptoms could be seen apart from the INO, I feel urged to combine them into an overlapping disease. Because of the delay between the general symptoms and the INO, a pure neurological disease is less likely.
When we combine the INO and the general symptoms, my differential diagnosis would be:
1. Systemic Lupus Erythematosus (with neurologic component) or another auto-immune disease (hypothyreoidis m?)
2. Infectious (borrelia, lues)
3. MS
4. Tumor
I would like to know the following
- Lhermitte's sign positive? Random numbness/tingles?
- Was she completely healthy before start of symptoms?
- Sources of infection: i.e. insect bites (ticks), visitis to foreign countries, unsafe sex...
- Weight loss, nocturnal hyperhydrosis, fever
- Family history of MS or other auto-immune diseases
If not you should describe about it :)
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