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A 34 year old woman with a history of well controlled hypothyroidism, presents to clinic with double vision. She complains that the visual disturbance is constant and worsens when she looks to the right. She describes seeing singular objects “side by side”.
Your Assessment
Which of the following is the most likely diagnosis?
A. Oncologic process
B. Hematologic process
C. Endocrinologic process
D. Cardiovascular process
E. Infectious process
F. Rheumatologic process
Global Morning Report (GMR) is a daily series of fun, interactive, and brief clinical cases for physicians and trainees to practice their clinical reasoning in just a few minutes each day. GMR is a medical education initiative from the Human Diagnosis Project.
A 34 year old woman with a history of well controlled hypothyroidism, presents to clinic with double vision. She complains that the visual disturbance is constant and worsens when she looks to the right. She describes seeing singular objects “side by side”.
Your Assessment
Which of the following is the most likely diagnosis?
A. Oncologic process
B. Hematologic process
C. Endocrinologic process
D. Cardiovascular process
E. Infectious process
F. Rheumatologic process
Review of systems reveals no headaches, eye pain, limb weakness, bowel or bladder issues. She also denies reent travel, fever or sick contacts.
Your Assessment
A. Oncologic process
B. Hematologic process
C. Endocrinologic process
D. Cardiovascular process
E. Infectious process
F. Rheumatologic process
Your Assessment
A. Oncologic process
B. Hematologic process
C. Endocrinologic process
D. Cardiovascular process
E. Infectious process
F. Rheumatologic process
Her vital signs are within normal range and her physical exam is normal with the exception of her neurologic exam.
Neurologic exam:
- Cannot adduct her left eye when looking to the right side, her eyes can converge. She has nystagmus of right eye when she looks to the right side, but not to the left side.
- Remained of neurolgic exam within normal limits.
MRI brain reveals:
- Hyperintensity string on flair sequence over left pontine area, likely affecting medial longitudinal fasciculus (MLF), the lesion enhanced with contrast; it also showed multiple oval hyper intensity lesions without enhancement around lateral ventricle with typical "Dawson fingers" signs.
Your Assessment
A. Cavernous thrombosis
B. Ischemic stroke
C. Multiple sclerosis
D. Glioblastoma
E. Hydrocephalus
F. Sarcoidosis
G. Miller-Fisher syndrome
H. Benign intracranial hypertension
I. Hypothyroidism
Neurologic exam:
- Cannot adduct her left eye when looking to the right side, her eyes can converge. She has nystagmus of right eye when she looks to the right side, but not to the left side.
- Remained of neurolgic exam within normal limits.
MRI brain reveals:
- Hyperintensity string on flair sequence over left pontine area, likely affecting medial longitudinal fasciculus (MLF), the lesion enhanced with contrast; it also showed multiple oval hyper intensity lesions without enhancement around lateral ventricle with typical "Dawson fingers" signs.
Your Assessment
A. Cavernous thrombosis
B. Ischemic stroke
C. Multiple sclerosis
D. Glioblastoma
E. Hydrocephalus
F. Sarcoidosis
G. Miller-Fisher syndrome
H. Benign intracranial hypertension
I. Hypothyroidism
Lumbar puncture revealed:
- White count 5, glucose 45, protein 30
- Oligoclonal bands (+)
- NMO antibody (-)
- ACE(-)
Your Final Assessment
A. Cavernous thrombosis
B. Ischemic stroke
C. Multiple sclerosis
D. Glioblastoma
E. Hydrocephalus
F. Sarcoidosis
G. Miller-Fisher syndrome
H. Benign intracranial hypertension
I. Hypothyroidism
- White count 5, glucose 45, protein 30
- Oligoclonal bands (+)
- NMO antibody (-)
- ACE(-)
Your Final Assessment
A. Cavernous thrombosis
B. Ischemic stroke
C. Multiple sclerosis
D. Glioblastoma
E. Hydrocephalus
F. Sarcoidosis
G. Miller-Fisher syndrome
H. Benign intracranial hypertension
I. Hypothyroidism
The Human Dx medical community concluded answer C: Multiple Sclerosis. Solve more cases by signing up for Human Dx here.
Teaching Points
● Case resolution: Patient was diagnosed with Multiple Sclerosis (MS). At 3 month follow up, patient had resolved double vision and denied further attacks. She was started on a disease modifying medication for long term relapse prevention. Based on the clinical presentation, this is a presentation of a first clinical attack of a pontine demyelinating process like multiple sclerosis, the MRI coincidently showed findings of other silent lesions in the brain indicating temporal and spatial occurrences.
● Epidemiology: It presents anywhere from adolescence to 60 years of age with a strong female predilection female to male 2:1 incidence. Previous studies have shown that persons living farther away from the equator are more likely to develop MS. Low vitamin D was thought to be related to MS as well.
● Clinical presentation: MS is a chronic central autoimmune demyelinating disease, can be categorized by onset, recurrence and duration to primary progressive, secondary progressive, progressive relapsing, relapsing remitting (most common type). The classic MS is also called Charcot type. There are other variants: Tumefactive MS, Marburg (acute malignant), Schiller's (diffuse cerebral sclerosis) and Balo concentric sclerosis. Labs and imaging often rule out other potential diagnoses including stroke, sarcoidosis, lupus encephalitis or CNS infection etc. The recently 2017 revised McDonald criteria are applied for diagnosis (link below).
● Clinical pearl: Dawson's fingers are white matter plaques often perpendicular to the corpus callosum (seen in image).
● Treatment: Acute attack of MS regardless of initial presentation or a relapse is treated with IV methylprednisolone 1g/day for 3-5 days. Medications used for long term remission include interferon, glatiramer acetate, teriflunomide etc.
● Reference: Goldenberg, M. M. (2012). Multiple sclerosis review. P T, 37(3), 175-184.
● Image source from case contributed by A. Prof Frank Gaillard. Multiple sclerosis | Radiology Case | Radiopaedia.org.
● McDonald criteria: Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. - PubMed - NCBI
Teaching Points
● Case resolution: Patient was diagnosed with Multiple Sclerosis (MS). At 3 month follow up, patient had resolved double vision and denied further attacks. She was started on a disease modifying medication for long term relapse prevention. Based on the clinical presentation, this is a presentation of a first clinical attack of a pontine demyelinating process like multiple sclerosis, the MRI coincidently showed findings of other silent lesions in the brain indicating temporal and spatial occurrences.
● Epidemiology: It presents anywhere from adolescence to 60 years of age with a strong female predilection female to male 2:1 incidence. Previous studies have shown that persons living farther away from the equator are more likely to develop MS. Low vitamin D was thought to be related to MS as well.
● Clinical presentation: MS is a chronic central autoimmune demyelinating disease, can be categorized by onset, recurrence and duration to primary progressive, secondary progressive, progressive relapsing, relapsing remitting (most common type). The classic MS is also called Charcot type. There are other variants: Tumefactive MS, Marburg (acute malignant), Schiller's (diffuse cerebral sclerosis) and Balo concentric sclerosis. Labs and imaging often rule out other potential diagnoses including stroke, sarcoidosis, lupus encephalitis or CNS infection etc. The recently 2017 revised McDonald criteria are applied for diagnosis (link below).
● Clinical pearl: Dawson's fingers are white matter plaques often perpendicular to the corpus callosum (seen in image).
● Treatment: Acute attack of MS regardless of initial presentation or a relapse is treated with IV methylprednisolone 1g/day for 3-5 days. Medications used for long term remission include interferon, glatiramer acetate, teriflunomide etc.
● Reference: Goldenberg, M. M. (2012). Multiple sclerosis review. P T, 37(3), 175-184.
● Image source from case contributed by A. Prof Frank Gaillard. Multiple sclerosis | Radiology Case | Radiopaedia.org.
● McDonald criteria: Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. - PubMed - NCBI
Global Morning Report (GMR) is a daily series of fun, interactive, and brief clinical cases for physicians and trainees to practice their clinical reasoning in just a few minutes each day. GMR is a medical education initiative from the Human Diagnosis Project.
