case presentation-Cranial nerve 6 and 12 palsy1.pptx

CN IV and IXX palsy in a patient of TB meningitis.

1. BIODATA 40 years old female patient Bakht Zari W/O Ghulam Murtaza, married, muslim, homemaker by profession , R/O Shahdara town Lahore was admitted on 19 of MAY 2023 with following presenting complain of.

2. PRESENTING COMPLAIN Binocaular diplopia for 2 and half years.

3. HISTORY OF PRESENTING ILLNESS My patient normoglycaemic and K/C of hypertension for last 10-12 years , poorly compliant with medication, poorly controlled and doing her daily activities normally, and independently 2 and half years back when she developed binocular diplopia , sudden in nature and static since then with no improvement.. second image is seen by her on left horizontal direction , diplopia worsened by looking in left lateral direction and relived by closure of one eye

4. T here is associated C/O restriction of movement of left eye in left lateral gaze. At same time she developed blurring of vision in left eye which improved by use of glasses.

5. . there is associated Hx of headache for last 20-25 years , episodic , episode lasts 1-2 weeks and repeats once a month... headache is generalized with moderate in intensity in beginning , which is progressively worsening over time for last 2-3 years and not associated with nausea, vomiting , photophobia, phonophobia , not increase in intensity by postural change, straining, coughing,climbing stairs and relived by analgesics and headche is also not worsened on morning rise. No associated Hx of fatiguability and improvement in diplopia in morning and ptosis of lids .

6. At same time, she developed C/O gradually decreasing hearing in left ear with ear fullness and tinnitus present all time with worsening over time. no ear discharge . T here is associated C/O dizziness and recurrent falls which is secondary to diplopia and dizziness not occuring at rest. No Hx of ataxia and resting or intention tremor and balance issues on walking... no Hx of angle of mouth deviation and unable to close eye and smell and taste disturbance No Hx of numbness in face and decreased sweating on any half of face and electrical shock like feeling in face on brushing and eating food.

7. One and half years back, she developed chewing difficulty and swallowing difficulty and she noticed tongue deviation towards left side on protruding forward that was gradual in onset and slowly progressing and decreased saliva production.. swallowing difficulty is more to solide and she said she swallows with use of water and no nasal regurgitation of liquid and coughing on eating food. A t same time, she developed voice quality change.

8. During thess 2 and half years, she had not developed limb weakness, numbness in limbs and and creeping sensation in limbs. No Hx of urinary and fecal incontinence or retention. she had also C/O multiple joints pain for last 2,3 hours which is symmetrical and more in small joints with no morning stifness and no swelling and no redness and no associated Hx of oral ulcer , genital ulcers, hair loss, photosensitivity rash, malar rash . Also C/O generalized muscular pain which responds to painkiller,

9. No hx of swelling in neck, nervousness , diarrhe , constipation.. no previous history of dry cough and dyspnea on exertion . no hx of weight loss, night sweats , low grade fever and lumps an bumps in body, no hx of frothy urine, haematuria , and periorborbiatl swelling...

10. Past History Patient had history of pulmonary TB 5-6 years back for which she took ATT 9 months and recovered from it fully.. she had also past history of bilateral lower limb weakness after birth of her baby 3-4 years back for 1 month , no record available of it.. accoring to her.. she had severe pain and unable to move her lower limbs and local GP avised deltacortil for it and she recovered fully...

11. Personal history She is non smoker, non alcoholic and no history of any substance use... She also eats normal pakistani diet and is not pure vegetarian. she eats red meat once a month.

12. Socioeconomic history She has a family of 7 members with one daughter and four sons. She lives in a house of 2 marla of her husband. She belongs to lower middle class.

13. General Physical Examination A middle aged lady of average built and height was sitting comfortably in bed, fully cooperative during examination and well oriented in time, place and person, With Pulse rate of 76bpm, regular in rhythm with no R-R,/ R–F delay...All peripheral pulses were palpable. Bp = 110/80mmHg.. Equal in both arms. R/R =18/m Temp =98F Blood sugar level was 126 mg/dl

14. No palor Clubbing, cyanosis, jaundice, joint deformities or malar rash. No Xanthalesmas,xanthomas , raised jvp , thyroid swelling or any palpable lymph nodes or pedal edema . Carotid bruit was absent. Orodental hygiene was good. Spinal Tenderness Or deformity was absent.

15. CNS examination GCS was 15/15 Higher mental fuctions were intact

16. Lower limbs Right Left Bulk N N Tone N N Power P=5/5....D=5/5 P=5/5... D= 5/5 Reflexes K=+2 A=+2 K=+2 A=+2 Planters downgoing downgoing

17. Upper Limb Right Left Bulk N N Tone N N Power 5/5 5/5 Reflexes B=+ 2 T=+ 2 B=+2 B=+2 T=+2 B=+ 2

18. Coordiation and gait are intact in upper limbs and lower limbs. sensory system is istact... other cerebellar signs are also intact,, language perception, repetition, articualtion and motor component intact with change in voice quality...

19. Cranial nerve examination Cranial nerve 1 examination is normal.. On inspection of eyes, left eye is medially deviated V/A is 6/18 in left eye and 6/30 in right eye , at time of examination she had no glasses with her.. colour vision and visual field intact.. pupils normal and reactive to light.. fundus examination un remarkable .. On cranial nerve 3,4,6 examination, left eye unable to abduct and rest of movements are intact with binocular diplopia present and it improves with eye closure. Cranial nerve 7 and 5 is intact.. On 8 nerve examination.. There was decreased hearing in left ear

20. on rinnie test, air conduction is greater than bone conduction but less as comapered to right ear in left ear and weber is central with no lateralization On 9,10 nerve examination.. uvula is central in line with equal movement of soft palate bilaterally on AAH test , cough reflex and gag reflex is also inatact On tongue examination, there is decreased bulk on left half of tongue and tongue deviated to left side on protrusion with movements decreased on left side as compared to right side Cranial nerve 11 examination is unremarkable....

21. Systemic examination CVS; A.B in left 5 ICS med to MCL, S1+S2 No murmur GIT ; Soft Non tendor , no palpable visceromegaly Bowel sounds are audible Respiratory system; NVB+ 0

22. Case summary 40 years old hypertensive female patient presented with C/O binocular diplopia for 2 and half years and then 1 and half years back, she developed chewing and swallowing difficulty with Hx of pulmonary TB 5 years back O/E she had left lateral rectus palsy with decreased bulk of left half of tongue aand tongue deviated to left side

23. Differential diagnosis Multiple cranial nerve neuropathies due to... Vasculitis secondary to autoimmune disease Neurosarcoidosis Relapsing remitting multiple sclerosis TBM Paraneoplastic neuropathy

24. Favouring points Non favouring points Vasculitis episodic mutltiple cranial nerves involved slowly progressive disease hx of multiple joints pain joints pain is not associated with morning stiffness, no oral ulcers, no malar rash, no photosensitivity., only nerves on one side involved neurosarcoidosis RRMS TBM disease slowly progressing with multiple cranial nerves involved , hx of multiple joints pain disease involved in episodes with remission in between, hx of slowly progressive disease with involvement of multiple cranial nerves on one side secondary to meningeal entrapment with hx of treated pulmonary tb most common infection most common nerve involved is fascial nerve , no Hx of cough and dyspnea no hx of optic neuritis , no hx of involvement of nerves on right side no hx of weight loss, fever and night sweats, paraneoplastic neuropathy or primary brain tumor slowly progressing disease, with meninges involved and only one side is involved no hx of weight loss, fever and night sweats, no hx of primary cancer, cranail nerves involved in episodes

25. Investigatio ns Cbc = Hb . 12.3 , TLC. 9.4 , PLT. 361 LFTs= Bill. 0.3 ,ALT.24 , AST. 37, RFTs=Urea.22 , Creat . 0.81 S/E=Na.138, K. 4.2,, Cl=105 E CG Showed normal rate, rhythm and axiS . S.ca is 9.2 and albumin is 4.7 ACE level is 30.5.... TFTs normal....

26. CSF ANALYSIS CSF analysis shows protein with 43.8 mg/dl and glucose is 59 mg/dl Cell count is less than 5 with negative staining for AFB and gram staining..... No RBCs and xanthochromia seen

27. Audiometry Audiometry shows left moderate to severe mixed hearing loss.. tympanometry shows slightly reduced compliance in left ear that probably indicates stiffness of middle ear system (otosclerosis /tympanosclerosis)...

28. MRI on 23/11/23 MRI BRAIN AND ORBIT WITH IV CONTRAST dated 23/11/23 shows left lateral rectus atrophied as compare to right, T2WI/ flair hyperintense signals noted along left petrous apex with dural thickening, extending upto prepontine region and left cavernous sinus showing post contrast enhancement....

29. MRI ON 17/4/24 MRI BRAIN AND ORBIT WITH IV CONTRAST dated 17/4/2024 shows abnormal enhancing dural thickening noted in left petrous apex , prepontine cistern, and cavernous sinus partially encasing intracavernous ICA however maintaining its flow void.. ipsilateral mastoiditis noted and mild inflammatory changes seen in left sphenoid sinus...

30. Diagnosis