Case 158

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #158

Date of Consultation: 5-14-2009

HISTORY OF PRESENT ILLNESS:

This 27-year-old right-handed white female was diagnosed with non-Hodgkin’s lymphoma in August of 2008. Between September 2008 and December 2008, she received 6 cycles of chemotherapy.

In January 2009, she developed weakness of the left side of the face and difficulty swallowing food. She was started on intrathecal chemotherapy in March, and her last dose of intrathecal chemotherapy was on May 6, 2009.

She also received whole brain radiation, which was completed on March 4, 2009.
Over the past one to two months, the patient has been having increasing difficulty with pain involving head, neck, back, and all four limbs. She describes the pain as a burning sensation with some tingling and pins and needles characteristics.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: No deficits of orientation, speech, or memory were present. The patient’s mood was irritable because of the severe pain.

Cranial Nerves: Sensation of smell was not tested. Visual field, visual acuity, and funduscopic examinations were normal. External ocular movements were full without nystagmus or diplopia. Pupils were equal, round, and reactive to light. Sensory and motor functions of the Vth cranial nerve were normal. Muscles of facial expression were normal on the right but weak on the left. The left facial weakness included the inability to elevate the eyebrows, wrinkle the forehead, close the eyes forcefully, and grimace. Hearing was intact bilaterally. With vocalization, the soft palate contracted asymmetrically, and the uvula moved to the left. The gag reflex was diminished with stimulation of the right side of the pharynx but was intact with stimulation of the left side. Tongue movements were normal.

Motor System: There were no areas of focal or generalized muscular atrophy. There were no fasciculations. Muscle tone and power were normal in all four limbs, when allowing for her pain.

Reflexes: Deep tendon reflexes were diminished in all four limbs. The plantar reflexes were flexor bilaterally.

Sensory System: Sensory examination was normal to all modalities bilaterally.

Cerebellar Function: Finger-to-nose and heel-to-shin tests were normal.

Gait and Stance: Not tested due to the patient’s discomfort.

Questions

1. Is the weakness of the left side of the face of the upper motor neuron or lower motor neuron type?

2. Why was this patient having difficulty swallowing food?

3. Was the involvement in this case intrinsic to or extrinsic to the central nervous system?

4. Is the pathologic process in this patient localized or multifocal?

5. List the structures that were involved by the pathologic process to produce each of the abnormal signs and symptoms experienced by this patient.

6. In general, what type of pathologic process do you think is involved in this case?

7. What diagnostic procedure(s) would you undertake at this point?

Answers