A 26-year-old woman comes to the emergency department with numbness and weakness of both legs. Throughout the prior day, she felt like her legs kept "going to sleep" and on waking this morning, she had difficulty standing up and walking. She also reports urinary urgency and 2 episodes of involuntary urine leakage. The patient has no history of back pain or trauma. Four years ago, she was diagnosed with type 1 diabetes mellitus, and her glycemic control is maintained by continuous subcutaneous insulin infusion pump. One year ago, she was evaluated for right eye pain and impaired vision, but these resolved spontaneously in a week. Temperature is 36.9 C (98.4 F), blood pressure is 134/78 mm Hg, and pulse is 76/min. Visual acuity and pupillary reflexes are normal. Muscle strength in the right and left lower extremities are 3/5 and 4/5, respectively. Patellar reflexes are 3+ on both sides, and plantar reflexes are upgoing. Sensation to vibration, light touch, and pain is decreased in both legs. Her fingerstick glucose level is 144 mg/dL. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 26-year-old woman comes to the emergency department with numbness and weakness of both legs.  Throughout the prior day, she felt like her legs kept "going to sleep" and on waking this morning, she had difficulty standing up and walking.  She also reports urinary urgency and 2 episodes of involuntary urine leakage.  The patient has no history of back pain or trauma.  Four years ago, she was diagnosed with type 1 diabetes mellitus, and her glycemic control is maintained by continuous subcutaneous insulin infusion pump.  One year ago, she was evaluated for right eye pain and impaired vision, but these resolved spontaneously in a week.  Temperature is 36.9 C (98.4 F), blood pressure is 134/78 mm Hg, and pulse is 76/min.  Visual acuity and pupillary reflexes are normal.  Muscle strength in the right and left lower extremities are 3/5 and 4/5, respectively.  Patellar reflexes are 3+ on both sides, and plantar reflexes are upgoing.  Sensation to vibration, light touch, and pain is decreased in both legs.  Her fingerstick glucose level is 144 mg/dL.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d14e_ec21_bc81_01f0d2b2636b_MD0003_00 This patient likely has multiple sclerosis (MS), an autoimmune inflammatory demyelinating disorder of the central nervous system (CNS) that typically presents with neurologic deficits disseminated in space and time in women age 15-50. MS should be suspected in patients with >2 distinctive episodes of CNS dysfunction with at least some resolution that cannot be explained by a single lesion. Symptoms occur over hours to days and then improve over weeks to months, although some may be permanent. Common initial symptoms may include: > Optic neuritis: monocular visual loss, painful eye movements, and afferent pupillary defectTransverse myelitis: motor and sensory loss below the level of the lesion with bowel and bladder dysfunction. Patients initially have flaccid paralysis (spinal shock), followed by spastic paralysis with hyperreflexia.Internuclear ophthalmoplegia: demyelination of the medial longitudinal fasciculus resulting in impaired conjugate horizontal gaze in which the affected eye (ipsilateral to the lesion) is unable to adduct and the contralateral eye abducts with nystagmusCerebellar dysfunction: intention tremor, ataxia, and nystagmus Optic neuritis: monocular visual loss, painful eye movements, and afferent pupillary defect Transverse myelitis: motor and sensory loss below the level of the lesion with bowel and bladder dysfunction. Patients initially have flaccid paralysis (spinal shock), followed by spastic paralysis with hyperreflexia. Internuclear ophthalmoplegia: demyelination of the medial longitudinal fasciculus resulting in impaired conjugate horizontal gaze in which the affected eye (ipsilateral to the lesion) is unable to adduct and the contralateral eye abducts with nystagmus Cerebellar dysfunction: intention tremor, ataxia, and nystagmus (Choice A) This young patient without cardiovascular risk factors is unlikely to have had a stroke. In addition, anterior cerebral artery occlusion would lead to acute-onset contralateral leg weakness. (Choice B) Diabetic polyneuropathy causes symmetric sensory loss in a "stocking-glove" distribution. It occurs insidiously, approximately 5 years after a diagnosis of type 1 diabetes mellitus, and can have associated decreased/absent ankle reflexes initially with progression to involve other reflexes. Severe cases may be associated with muscle weakness. (Choice C) Guillain-Barré syndrome leads to rapidly progressive ascending muscle paralysis generally preceded by infection (eg, Campylobacter jejuni, viruses). Associated symptoms often include reduced/absent reflexes and paresthesias. Optic neuritis is not characteristic. (Choice E) A symptomatic parasagittal meningioma would likely cause progressive neurologic deficits (eg, bilateral lower extremity weakness/numbness) and seizure due to growth and compression of localized brain structures. Patients may also develop symptoms of elevated intracranial pressure (eg, headache, nausea/vomiting). (Choice F) Vitamin B₁₂ deficiency occurs due to long-standing poor absorption (eg, pernicious anemia, Crohn disease) or lack of dietary animal products (eg, vegan diet). Patients typically develop subacute combined degeneration of the spinal cord leading to progressive symmetric sensory loss/paresthesias, sensory ataxia, and spastic muscle weakness. Educational objective: Multiple sclerosis should be suspected in young women with neurologic deficits disseminated in space and time. Common presentations include optic neuritis (eg, monocular blindness, painful eye movement) and transverse myelitis (eg, motor and sensory loss below the level of the lesion, incontinence). References: Diagnosis and differential diagnosis of multiple sclerosis. (http://www.ncbi.nlm.nih.gov/pubmed/23917094) Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. (http://www.ncbi.nlm.nih.gov/pubmed/21387374)

A 26-Year-Old Woman Comes to the Emergency Department with Numbness