A patient presents with recurrent optic neuritis of both eyes with extensive transverse myelitis. Visual acuity in right eye is 6/60 and visual acuity in left eye is 6/18. Patient showed 50% response to steroids. Diagnosis is:
Ans. A. Neuromyelitis optica (NMO)* Clinical scenario matches classic Wingerchuk criteria. (Optic neuritis + simultaneous transverse myelitis). So it is a case of neuromyelitis optica.Diagnostic Criteria for NMO* Required:- Optic neuritis- Acute transverse myelitis* Supportive (2 of 3 criteria required):- Longitudinally extensive cord lesion extending over 3 or more vertebral segments- Brain magnetic resonance imaging normal or not meeting criteria for multiple sclerosis- Aquaporin-4 seropositivity- 'Cloud-like appearance sometimes seen in MRI- CSF findings: Pleocytosis, neutrophils, and eosinophils- Next investigation will be Anti NMO IgG (in blood > CSF)- Best treatment: Steroids + IV IgSubacute Combined Degeneration of Spinal Cord* Loss of reflexes due to an associated peripheral neuropathy* Diagnostic clue: Babinski sign* Optic atrophy and irritability seen in advanced cases* Lab findings: Macrocytic red blood cell, low serum B12 concentration, elevated serum homocysteine* Best investigation: Antiparietal cell antibodies and Schilling test* Treatment: Vitamin B12 therapy (1000 pg given intramuscular at regular intervals)Neurosyphilis* Neurological involvement: Argyll-Robertson pupil, Tabes dorsalis, general paresis, rarely a gumma or aortitis.* Initial diagnostic test:- Lumbar puncture for neurosyphilisFTA is 100% sensitive in CSFCSF VDRL is only 50% sensitive* Treatment: IV penicillin. Desensitize if the patient is penicillin allergic.
Neuromyelitis optica (NMO)
Subacute combined degeneration of spinal cord (SACD)
Posterior cerebral artery stroke
Neurosyphilis
C.N.S.