Dr. Md Rashedul Islam FCPS, MRCP(UK)

Registrar, Neurology, BIRDEM

A 56 years old diabetic right handed gentleman,

hailing from Gazipur, got admitted in BIRDEM

General Hospital on 10th October,14 with the

complaints of-

• Drooping of eyelid for 2 months

• Headache for 3 months

According to the statement of the patient, he was reasonably well 3 monthsback. Then he developed headache which was gradual on onset, global, dull aching in nature, mild in severity. It was not associated with radiation, vomiting, eye ache, exaggerated at morning & coughing. It was relieved with medication.

H/O Present illness

He also has complaints of drooping of both eyelid which was gradual on onset, asymmetrical, double vision, eye ache. On detailed query he gives h/o fever for 3 months which was low grade, intermitted, associated with generalized weakness. It was not associated with chill & rigor, night sweating, diurnal variation, cough, weight loss.

H/O Present illness

With the above complaints, he visited opthalmologist & neurologist outside BIRDEM & investigated. He was diagnosed as bilateral opthalmoplegia due to mononeuritis multiplex due to diabetes mellitus. He was referred to Neurology, BIRDEM for further investigation & management.

CT Scan of Brain

CT Scan of Brain

H/O past illness: Nothing contributory Socioeconomic history: He belongs to a middle class family

Personal history:

He is non alcoholic, non smoker

Family history:

Nothing significant

Treatment history:

Tab. Glimiperide

Tab. Vit B complex

General examination:

Appearance: ill looking, bilateral ptosisBuilt: average Decubitus: on choiceAnaemiaJaundiceCyanosisOedemaDehydrationClubbingKoilonychiaLeukonychia

Absent

General examination:

Neck vein: not engorged

Thyroid: not enlarged

Lymph node: not palpable

Skin pigmentation & body hair distribution: normal

Pulse: 86 b/min

BP: 130/80 mmHg

Temp:98 F

RR: 16 breaths/min

• Higher psychic function : Conscious, Oriented• Speech: Normal• Cranial nerves :

Complete opthalmoplegia on right eye

3rd, 4th & partial 6th nerve palsy on left eye• Fundus: Normal• GCS: 15/15

NERVOUS SYSTEM EXAMINATION

Video clips

Muscle Rt. UL Lt. UL Rt. LL Lt. LL

Bulk Normal Normal Normal Normal

Tone Normal Normal Normal Normal

Power Normal Normal Normal Normal

Involuntary movement

Absent Absent Absent Absent

MOTOR FUNCTION:

Reflex B T S K A Abd Plantar

Right ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ Present Flexor

Left ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ Present

Flexor

Sensory system:

Pain Temp Touch Vibration

Position sense

Right upper limb

Intact

Right lower limb

Left upper limb

Left lower limb

• Sign of Meningeal irritation - Absent

• Cerebellar sign : Absent

• Gait: Absent

Systemic examinations

Other systemic examination was normal

A 56 years old gentleman hailing from Gazipur got admitted in Neurology with the complaints of headache which was gradual on onset, global, dull aching in nature, mild in severity. It was not associated with radiation, vomiting, eye ache, exaggerated at morning & coughing.

Salient feature

Salient feature

He also has complaints of drooping of both eyelid which was gradual on onset, asymmetrical, double vision, eye ache. On detailed query he gives h/o fever for 3 months which was low grade, intermitted, associated with generalized weakness. It was not associated with chill & rigor, night sweating, diurnal variation, cough, weight loss.

Salient feature

On examination , he is ill looking, Conscious, Oriented, Complete opthalmoplegia on right eye, 3rd, 4th & partial 6th nerve palsy on left eye. Fundoscopy & other systemic examination is normal. There is no sign of meningeal irritation.

Provisional diagnosis

• Diabetes Mellitus Type 2

• Basal meningitis

Differential diagnosis

• Myaesthenia gravis

• ICSOL involving brain stem

• Mononeuritis cranial multiplex

• Cavernous sinus thrombosis

Investigations

CBC:

Hb % - 13.2

WBC -7000 cu/mm

Neu-45 %

Lymph- 47 %

Mono -5.9 %

Eosino- 1.1%

Platelet- 195000

ESR- 82mm in 1st hour

S. Electrolytes

Na-136 mmol/l

K-4.5 mmol/lCl: 106 mmol/lHCO3: 25 mmol/lCa- 9.2 mmol/lMg- 0.8 mmol/lPhosphate-3.8

Lipid profile:

TG: 166 mg/dl

T. Chol : 144 mg/dl

LDL: 85 mg/dl

HDL: 40 mg/dl

LFT:

ALT: 28 iu/L

AST: 36 iu/L

RFT:

S. Creatinine: 0.8mmol/l

S Urea: 31 mmol/l

HbA1c: 6.2%

Sugar - Nil

Albumin – Nil

Ketone- Nil

Epi. cell: A few /HPF

Pus cell: 1-2 /HPF

RBC: Nil

URINE R/M/E

Chest X-Ray

NORMAL

ECG

Normal

MRI of Brain

MRI of Brain

MRI of Brain

MRI of Brain

MRI of Brain

MRI of Brain

Special investigations

ANA: Negative

P-ANCA: Negative

C-ANCA: Negative

VDRL: non- reactive

TPHA: non- reactive

CRP: 46 mg/l

MT: 6mm

CSF study

• Appearance: clear

• Protein: 136g/L

• Sugar: 3.2mmol/L( Corresponding blood glucose-12mmol/l)

• Cell count: Total WBC 350 cells/cmm

• Lymphocytes: 99%

• Total RBC: 25cells/cmm

• Bacterial antigen: Negative

Final diagnosis:

• Diabetes mellitus type 2

• Tubercular meningitis

Treatment:

Short acting insulin

Anti TB drugs

Tab. pyridoxine

Tab. Prednisolone

Supportive treatment

Patient was counseled about Course and prognosis of the disease

Follow UP

Patient was advised to follow up in Neurology after 2 weeks for further clinical evaluation & management

Video clip

• Oculoparesis is improved along with ptosis

Acknowledgement :

Department of Ophthalmology