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October 1st, 2008October 1st, 2008

Jon-Emile Kenny M.D.Jon-Emile Kenny M.D.

Chief ComplaintChief Complaint

28 male presents with left lower 28 male presents with left lower extremity weakness and parasthesias extremity weakness and parasthesias for several weeks.for several weeks.

History of Present IllnessHistory of Present Illness

One year earlier, the patient had a similar One year earlier, the patient had a similar presentation. Work up at that time included an presentation. Work up at that time included an MRI, which was unremarkable. MRI, which was unremarkable.

His current episode started several weeks ago His current episode started several weeks ago and is associated with an inability to walk and and is associated with an inability to walk and impaired bladder and sexual function. impaired bladder and sexual function. Furthermore, he has lost approximately 50 lbs Furthermore, he has lost approximately 50 lbs over the past year. over the past year.

HistoryHistory

Past Medical History:Past Medical History:– Anterior and posterior uveitis Anterior and posterior uveitis – Periodic oral ulcersPeriodic oral ulcers– Bilateral pyelonephritis 2005Bilateral pyelonephritis 2005

Past Surgical History: Past Surgical History: – nonenone

HistoryHistorySocial Hx:Social Hx: No toxic habitsNo toxic habitsFamily Hx:Family Hx: Non-contributoryNon-contributoryAllergies: Allergies: No known drug allergiesNo known drug allergiesMedications:Medications:– nonenone

Review of Systems: Review of Systems: – Exercise tolerance significantly reduced from his Exercise tolerance significantly reduced from his

baseline of 20 blocks and daily work-outs at the gymbaseline of 20 blocks and daily work-outs at the gym– Remainder of review of systems negataiveRemainder of review of systems negataive

Physical ExamPhysical ExamGeneral:General: young male in no acute distress, sitting young male in no acute distress, sitting

comfortably, Alert and Oriented x3.comfortably, Alert and Oriented x3.

T:98.8T:98.8ooF BP:98/62 HR:88 RR:18 F BP:98/62 HR:88 RR:18 OO22:99%RA:99%RA

HEENT:HEENT: multiple aphthous ulcers along edge of multiple aphthous ulcers along edge of tongue, no conjunctival injection. tongue, no conjunctival injection.

Neuro:Neuro: cranial nerves II-XII intact and symmetrical. cranial nerves II-XII intact and symmetrical. 4/5 motor strength and 1+ reflexes in left lower 4/5 motor strength and 1+ reflexes in left lower extremity. No saddle anesthesia.extremity. No saddle anesthesia.

The remainder of the physical exam was normalThe remainder of the physical exam was normal

LaboratoryLaboratory

WBC 12.9 mmWBC 12.9 mm33 (nl 4.5-11) (nl 4.5-11)

Hemoglobin 12.7 g/dL (13.5-16.5), MCV 89.9Hemoglobin 12.7 g/dL (13.5-16.5), MCV 89.9

Coagulation studies normalCoagulation studies normal

Liver enzymes normalLiver enzymes normal

Urinalysis negativeUrinalysis negative

CSF: normal protein and glucose, WBC 7 (27%P, CSF: normal protein and glucose, WBC 7 (27%P, 67%L, 6%M), VDRL negative, IgG normal.67%L, 6%M), VDRL negative, IgG normal.

ImagingImaging

Chest XR: normalChest XR: normal

Brain MRI:Brain MRI: Increased T2 signal of the thoracic Increased T2 signal of the thoracic cord from T6-L1 with minimal enhancement and cord from T6-L1 with minimal enhancement and cord expansion, smaller areas of increased cord expansion, smaller areas of increased signal at C3/4 and T2-5. Lesions in the corpus signal at C3/4 and T2-5. Lesions in the corpus callosum and right internal capsule with callosum and right internal capsule with gadollinum enhancement. gadollinum enhancement.

Differential DiagnosisDifferential Diagnosis

Neuro-Behcet’s DiseaseNeuro-Behcet’s Disease

Multiple SclerosisMultiple Sclerosis

Systemic Lupus ErythematosusSystemic Lupus Erythematosus

Neuro-SyphilisNeuro-Syphilis

Hospital CourseHospital Course

The patient had the following lab studies drawn:The patient had the following lab studies drawn:– ESR 24 (mild elevation)ESR 24 (mild elevation)– RPR negative RPR negative – ANA negative ANA negative – lyme titers negative lyme titers negative – SS-A/B negative SS-A/B negative – HTLV negative HTLV negative – ACE negative ACE negative – ANCA negative ANCA negative – anti-cardiolipin negative anti-cardiolipin negative – Hepatitis B/C negativeHepatitis B/C negative

Hospital CourseHospital Course

The patient was started on a 5 day course of IV The patient was started on a 5 day course of IV solumedrol with a significant response; his solumedrol with a significant response; his urinary symptoms and weakness resolved. His urinary symptoms and weakness resolved. His course was uncomplicated and he was course was uncomplicated and he was discharged on a steroid taper.discharged on a steroid taper.

Final DiagnosesFinal Diagnoses

Neuro-Behcet’s DiseaseNeuro-Behcet’s Disease

Follow-upFollow-up

Pt. has since had one recurrence of his Pt. has since had one recurrence of his symptoms. He has responded well to inpatient symptoms. He has responded well to inpatient cyclophosphamide and colchicine maintenance cyclophosphamide and colchicine maintenance therapy.therapy.