A 29-year-old man comes to the emergency department due to a week of progressive bilateral lower extremity weakness. He has no history of trauma or back pain. The patient had trigeminal neuralgia 3 months ago and a self-limited upper respiratory illness 2 weeks ago. His temperature is 37 C (98.6 F), blood pressure is 122/76 mm Hg, and pulse is 82/min. Physical examination shows increased resistance to passive flexion and extension of the lower limbs. Deep tendon reflexes are 3+ and plantar reflexes are upgoing bilaterally. There is decreased vibratory and positional sensation in his left upper extremity but no other sensory loss. A lumbar puncture is performed. Which of the following is most likely found on the cerebrospinal fluid analysis in this patient?

Question

A 29-year-old man comes to the emergency department due to a week of progressive bilateral lower extremity weakness.  He has no history of trauma or back pain.  The patient had trigeminal neuralgia 3 months ago and a self-limited upper respiratory illness 2 weeks ago.  His temperature is 37 C (98.6 F), blood pressure is 122/76 mm Hg, and pulse is 82/min.  Physical examination shows increased resistance to passive flexion and extension of the lower limbs.  Deep tendon reflexes are 3+ and plantar reflexes are upgoing bilaterally.  There is decreased vibratory and positional sensation in his left upper extremity but no other sensory loss.  A lumbar puncture is performed.  Which of the following is most likely found on the cerebrospinal fluid analysis in this patient?

Quizplus · Accepted Answer

11ec25c8_d53f_6051_bc81_6b3720fc8d01_MD0003_00 This patient's neurologic deficits disseminated in space and time (eg, trigeminal neuralgia, spastic lower limb paralysis, left upper limb sensory loss) indicate a diagnosis of multiple sclerosis (MS). When the diagnosis is suspected but the clinical examination or MRI is not classic, lumbar puncture should be performed for cerebrospinal fluid (CSF) analysis; such analysis shows oligoclonal bands in 85%-95% of patients. MRI In MS, the opening pressure and CSF appearance are typically normal (Choice C). CSF analysis usually shows a normal cell count with T lymphocyte predominance. There is also usually a normal total protein concentration, but immunoglobulin levels (particularly IgG) are high relative to other proteins. (Choice A) Abnormal central nervous system (CNS) cytology can be seen in patients with malignancy involving the CNS (eg, lymphoma, leptomeningeal metastasis). These patients generally have headache and constitutional symptoms (eg, weight loss, fever, night sweats). (Choice B) Albuminocytologic dissociation (elevated CSF protein with a normal cell count) is characteristic of Guillain-Barré syndrome, which typically presents with rapidly progressive ascending paralysis generally preceded by infection (eg, Campylobacter jejuni, viruses). Associated symptoms often include reduced/absent reflexes and paresthesias. (Choice D) Neutrophilic pleocytosis is generally seen with bacterial CNS infections (eg, meningitis). Patients classically have headache, fever, and nuchal rigidity and less commonly develop focal neurologic deficits. (Choice F) A positive CSF VDRL is seen in neurosyphilis. In the early form of neurosyphilis, patients can have symptomatic meningitis; however, in the late form, they may have generalized paralysis associated with dementia and personality changes, or tabes dorsalis (eg, Argyll Robertson pupil, absent lower extremity reflexes, impaired vibratory and positional sense). (Choice G) The presence of 14-3-3 protein in the CSF indicates a neurodegenerative prion disease (eg, Creutzfeldt-Jakob disease). These patients usually have rapid and profound deterioration of mental status (eg, dementia, behavior changes) with startle myoclonus. Educational objective: When multiple sclerosis is suspected but clinical examination or MRI is not classic, a lumbar puncture should be performed for cerebrospinal fluid analysis; this analysis shows oligoclonal bands in 85%-95% of patients. Opening pressure, protein, and cell count are generally normal. References: Cerebrospinal fluid oligoclonal bands in multiple sclerosis and clinically isolated syndromes: a meta-analysis of prevalence, prognosis and effect of latitude. (http://www.ncbi.nlm.nih.gov/pubmed/23431079) Recommended standard of cerebrospinal fluid analysis in the diagnosis of multiple sclerosis: a consensus statement. (http://www.ncbi.nlm.nih.gov/pubmed/15956157)

A 29-Year-Old Man Comes to the Emergency Department Due to a Week