Multiple Cranial Neuropathy (A Teaching Case)
A 54-year-old right handed man was seen in the emergency room with a three day history of right ptosis, intermittent double vision and numbness of both hands. His symptoms progressed over a three day period, he developed bilateral ptosis, permanent diplopia, neck weakness, nasal voice, sialorrhea and dysphagia, initially for solids and then for liquids. Two weeks before admission, he had had an upper respiratory tract infection that resolved spontaneously. The patient reported a past history of pulmonary tuberculosis and occupational exposure to tantalum, baryte and iron dust. He had recently traveled to Israel, denied alcohol abuse, smoking or recent immunizations. His mother died at 35 years of a ruptured brain aneurysm.
On examination the patient's blood pressure was 135/85 mmHg, the pulse 82 beats per minute, the respiratory rate 20 breaths per minute and the temperature 36.8 °C. The neurological examination revealed normal mental status and dysarthria. Pupils were 3 mm in diameter and reactive to light. There was a bilateral ptosis, palsy of extraocular muscles (video 1) and a facial diplegia (video 2). An asymmetric palate and reduced gag reflex was also noted. On protrusion the tongue was slightly deviated to the right. The patient was unable to elevate his shoulders or extend his neck. Additionally, he had sensory ataxia and deep tendon reflexes were absent. Muscle strength was normal in all limbs (video 3).
A complete blood count, chemistry panel, and levels of serum electrolytes were normal. His condition rapidly deteriorated, requiring endotracheal intubation and close monitoring in the Intensive Care Unit for 15 days.
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