Case History #29

Date of Admission: 10-23-1978

HISTORY OF PRESENT ILLNESS:

This 33-year-old white male was admitted to the hospital because of inability to use his right eye.  Approximately 6 weeks prior to admission, he noticed that his right upper eyelid was drooping, and at the same time he noted intermittent but frequent double vision.  These symptoms gradually worsened over the next month until, by 2 weeks prior to admission, the ptosis and diplopia were essentially constant.  At that time, the patient began to notice weakness of the left side of the body involving both the upper and lower extremities.  He had difficulty manipulating things with his left hand, and when he walked he tended to drag the left foot.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was normal except for the following.  When the patient attempted to look directly forward, the right eye was deviated laterally and inferiorly.  External ocular movements were full in the left eye.  In the right eye, abduction was normal.  There was virtually no movement past the midline in adduction, no elevation of the eye was possible, and on attempted depression of the right eye there was only a mild intorting of the eyeball.  The right pupil was 2 mm larger than the left pupil, and the light reflexes in the right eye were absent.  There was a marked ptosis of the right eyelid.  There was a mild weakness of the lower facial muscles on the left. 

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal on the right side but was increased in the left upper and lower extremities.  Muscle power was normal on the right side.  On the left side, there was a diffuse weakness in both the upper and lower extremities, rated at 4/5.

Reflexes:  Deep tendon reflexes were 2/4 on the right side and 3 to 4/4 on the left side.  Ankle clonus was present on the left.  Plantar reflexes were flexor on the right and extensor on the left.

Sensory System:  Intact.

Cerebellar Function:  Intact.

Gait and Stance:  Regular gait was performed with spasticity, circumduction, and a tendency to drag the foot in the left lower extremity.  Tandem gait was not attempted.  The Romberg test was negative.

Questions:

1.  What is the cause of the diplopia and the ptosis?    

2.  Is the left facial weakness of the upper motor neuron or lower motor neuron type?

3.  How precisely can the neurologic lesion be localized in this case? 

4.  What specific structures are involved to produce the left UMN facial weakness?   

5.  What specific structures are involved to produce the left-sided weakness?  

6.  Why are the motor signs and ocular signs on opposite sides of the body?

7.  What is the location of the neurologic lesion, and which side of the nervous system is involved? 

8.  The findings in this case represent a classic neurological syndrome.  What is the name of that syndrome?

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

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