Case History #192

Date of Admission: 8-20-2011

HISTORY OF PRESENT ILLNESS:

This 38-year-old right-handed African-American male was admitted to the hospital because of bilateral lower limb numbness and tingling.  Five days prior to admission, the patient noted numbness and tingling in both feet.  Over the next five days, these sensations gradually ascended to the level of the buttocks and groin regions bilaterally.  The patient indicated that this numb, tingling sensation also affected his gait.  He felt that he could not walk as securely as he usually did, and he felt somewhat unsteady on his feet. 

Aside from these sensory symptoms, the patient denied any other neurologic signs or symptoms.  He noted no bowel or bladder incontinence or retention.  He denied any sharp shooting, radicular pain from the low back into either lower limb.  He also denied any weakness of the lower limbs.  He had no prior history of neurologic problems and no recent history of any type of infectious disease. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was entirely unremarkable. 

Motor System:  There was no evidence of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone and power were normal in all four limbs. 

Reflexes:  Deep tendon reflexes were equal, symmetric, and normally active in all 4 limbs.  Ankle jerks were present bilaterally.  Plantar reflexes were flexor bilaterally. 

Sensory System:  All modalities of sensation, including cortical sensations, were normal in all 4 limbs. 

Cerebellar Function:  The patient performed all cerebellar tests normally in all 4 limbs. 

Gait and Stance:  Regular gait was performed slowly and cautiously on a slightly widened base.  However, regular gait was not ataxic.  He had mild difficulty with tandem gait.  He was able to walk on his heels and toes.  The Romberg test was negative.

Questions:

1.  Is there evidence of peripheral nerve involvement in this case, and, if so, what is the level(s) of the involvement?  If peripheral nervous system involvement is present, how would you characterize that further?
            

2.  Is there evidence of dorsal or ventral root involvement or spinal nerve involvement in this case, and, if so, what is the level(s) of the involvement?

3.  Is there evidence of spinal cord involvement in this case and, if so, at what level?  If spinal cord involvement is present, what specific structures are involved by the pathologic process?
            
4.  Could the patient’s signs and symptoms be caused by a lesion anywhere else in the central nervous system?  If so, where would the lesion be located?  What facts would support or refute this site of lesion localization?
           
5.  In general, what type of pathologic process do you think is involved in this case?