47-yr-old lady with monoplegia: A case

A 47-yr-old lady presented with monoplegia and progressive neurological findings and multiple co-morbidities

1. A 47-year-old lady presenting with monoplegia Presented by- Dr. Jheelam Biswas Resident, Phase A, Palliative Medicine Orchid unit (Internal Medicine)

2. Mrs. Rashida 47 years Married Homemaker Hobiganj Admitted on 5/9/18 Particulars of the patient

3. Weakness of right upper limb for 2 weeks Chief complaint

4. Weakness of right upper limb for 2 weeks which was- Sudden onset Started with tingling and numbness of fingers, then gradually progressed over last 5 days to whole of the right upper limb Not associated with pain or sensory loss No history of neck pain, trauma, headache, fever or weakness of any other parts of her body. History of present illness

5. No difficulty in speech and swallowing No bowel or bladder involvement Non diabetic Normotensive She visited a local doctor who advised for NCS of Rt. Median nerve and managed conservatively. As her condition did not improved, she was referred to BSMMU.

6. Pain and swelling of multiple joints for 4 years which- -Involved MCP, PIP, wrists, elbow joints, ankle, metatarso-phalangeal joints -Bilateral symmetrical -Inflammatory in nature -Morning stiffness >1 hour She visited was labeled as a case of rheumatoid arthritis on the basis of clinical criteria by local physician and was given some medications that she could not mention. Background history

7. She was on irregular medication and follow up. She visited an internist 1 year back and was put on Methotrexate, Indomethacin and Deflazacort for 3 months. Her pain and swelling decreased. S he developed dry cough and breathlessness 3 months after starting treatment.

8. HRCT of chest was done and found to have B/L ILD with bronchiactatic changes . Methotrixate was stopped. Currently she is on - Salfasalazine - Leflunomide for 1 year She is on remission for 1 year

9. Tab. Salfasalazine (500mg)- 2+1+2 Tab. Leflunomide (10mg)- 0+0+2 Drug history

10. Married for 22 years with no living child No family history of DM, HTN, RA, Br. Asthma Obstetric and gynecological history Menopausal for 3 years History of abortion at 12 weeks 10 years back Family history

11. She is from a lower middle class family Immunization history Vaccinated with BCG vaccination Socioeconomic history

12. Pulse- 78 b/min Bp- 110/80 mmHg Temp- 98F Resp. rate-16 b/min Swan neck deformity in Rt little finger, Lt index and 4 th finger, lateral deviation of toes in Rt foot. No anemia, jaundice, cyanosis, edema, clubbing, koilonichia , leuconychia , thyromegaly , lymphandenopathy . General examination

13. Higher cerebral function- normal Cranial nerves- intact Motor system- - Muscle power MRC grade 1in Rt upper limb - Tone- reduced in Rt upper limb - No wasting or fassiculation - All jerks are normal. -Planter- equivocal on Rt. side Sensory- intact Fundoscopy - Normal Signs of meningeal irritation- absent Neurological examination

14. Hand -Swan neck deformity in Rt little finger, Lt index and 4 th finger. - No tender or swollen joints or Rheumatoid nodules Foot - Lateral deviation of toes in Rt foot. Spine- Normal Gait- Normal Musculosketeltal system

15. B/L fine crepitation present in lower zone of both lungs, more marked on Rt lung Not altered by cough Respiratory system

16. Rheumatoid arthritis with DPLD with monoplegia due to- Mononeuritis Multiplex Cervical myeloradiculopathy Acute stroke ICSOL Differential Diagnosis

17. 25/5/2017 10/9/18 Hb 10.6 g/dl 13.4 g/dl ESR 55 mm/1 st hr 20 mm 1 st hr WBC 4500/ cumm 10800/ cumm MCV 78 fl 86.0fl PBF Non specific findings Complete blood count

18. 25/5/17 6/9/18 Anti CCP antibody >200 U/ml (positive) 1108 U/ml CRP 12 mg/L (positive ) <3.2 mg/L (negative) SGPT 17 U/L 20 U/l S creatinine 0.8 mg/dl 0.69 mg/dl RBS 5.8 mmol /L 6.4 mmol /l S. electrolyte Na- 136 mmol /l K- 3.7 MMOL/L Urine R/E PC-10-15 HPF Anti phospholipid Ab negative

19. CXR (P/A view) – 6/9/18 Fine reticulonodular shadow in lower zone of rt. lung

20. HRCT of chest- 8/7/17

21. Suggestive of B/L interstitial lung disease with bronchiectatic change, more marked in lower lobes of both lungs. HRCT of chest

22. X ray cervical spine- 10/9/18 Cervical lordosis straightened Osteophyte in C5, C6 level Rudimentary cervical rib on left side

23. MRI of brain- 10/9/18

24. MRI of brain with contrast

25. T1W1 shows mixed signal intensity mass (3.5*2.7*3.3 cm) in left parietal region. On contrast thick irregular rim enhancement with central interlesional necrosis. Huge perifocal edema seen in T2 film. 3 rd and l eft lateral ventricles are compressed by the tumor. Impression: ICSOL in left parietal region, possibly Glioblastoma Multiforme . MRI of brain

26. ICSOL in left parietal region with RA with DPLD. Final Diagnosis

27. Thank You