Case of 34y/o ♀ c/c neurological Sx’s starting 1 and ½ yrs ago. Pt had sudden onset of numbness in the Lt.

arm &descending down the leg after strenous ex’s which caused difficulty in walking. This subsided within a few wks then she developed a relapse in both L/E which also caused difficulty in walking for few wks which became normal within 3wks of taking medication. Episodes of relapse and remissions were frequent in U/E and L/E having weakness along with abnormal vision, diplopia, & abnormal pupil responses with relative afferent pupil defect on Lt. Pt also developed loss of pinprick sensation in level of T4-T5 & was moody with episodes of anxiety &depression.

• No h/o previous surgery • No h/o neurological disorders , DM, HTN or cardiac diseases.

• Non-smoker with sedentary lifestyle

• GCS 15/15 • Orientation: Oriented, alert and cooperative • Speech: Dysarthric with slurred speech, at times comprehensible. • Cognitive: Emotional symptomatology mainly depression and a decline in recent memory and attention span.

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All CN’s intact except: CN 2: Funduscopic examination reveals optic disk palor bilaterally. • CN 3: Pupillary responses are abnormal. • Extraocular movements are full without nystagmus.

Motor examination
• Paresis in the left U/E 4/5 but right U/E reveals normal muscle power. • Paresis of the right and left L/E 3/5.

• Difficulty in coordination in U/E and L/E. ( rapid alternating movements, finger to nose and heel to shin) .

• Hyperreflexia of DTRs of both U/E and L/E • Bilateral Babinski present.

• Mild vibratory sensation lost in the distal U/E and L/E. • Intact to pin prick, light touch and temperature. • Intact sensation of the face. • Proprioception loss in both L/E to the level of the ankles.

• The patient has a positive Romberg's sign therefore patient has mild ataxia.

MRI scan report revealed abnormal and CSF analysis showed the presence of oligoclonal bands,when a laboratory procedure called CSF electrophoresis was taken & very high ratio of IgG to albumin. • The term oligoclonal bands means the presence in CSF of two or more protein bands of a specific immunoglobin (IgG) that have greater intensity than in the concurrent serum sample. This pattern of banding is seen in patients with ….?

• * MRI transverse brain section: shows multiple periventricular and white matter lesions. • There are 10 multiple patches of myelin) around different areas of the brain (white & gray matter junction, brain stem, & cerebellum).

• * MRI sagittal brain section: shows (multiple lesions (arrows) that radiates from the surface of the lateral ventricles).

• * MRI paired transverse brain slices: show many white-matter lesions (arrows). At the bottom it shows gadolinium (an intravenous dye) contrast & enhancement of one of the lesions (arrow) indicating permeability of the blood-brain barrier & disease activity in the past 2 mnths of pt’s life.

• * MRI of the patient’s spinal cord (sagittal & transverse sections): shows many white lesions in some areas.

• Spinal tap (lumbar puncture): a small sample of CSF was removed within the patient’s spinal canal at the level of (L4-L5) that showed CSF IgG concentration is increased relative to other CSF proteins (e.g., albumin) and CSF gel reveals oligoclonal bands that are not present in a matched serum sample. • Visually Evoked Potential (VEP): showed abnormal result (slow optic nerve conduction response). • Brain Stem Evoked Response (BAER): showed (normal speed & response of transmission to CN 8). • Somatosensory Evoked Potential (SSEP): showed abnormality in all 4 limbs.

? What is the Possible Diagnosis

Thank You