Patient was apparently normal 3 days ago, on waking up in the morning she found her left eye was red on looking into the mirror. While attempting to close she was unable to close the Left eye .
She had double vision , which was maximum on looking to the right. On closing one eye double vision disappeared . Relatives noted inward ( nasal) deviation of right eye ball.
She was also having difficulty in swallowing both for solid and liquids , however the symptoms were mild and despite it she was able to eat normally at the time of admission. She had mild slurring of speech
MOTOR SYSTEM RIGHT LEFT UPPER LIMB LOWER LIMB UPPER LIMB LOWER LIMB BULK NORMAL NORMAL NORMAL NORMAL TONE NORMAL NORMAL NORMAL NORMAL POWER 5/5 4/5 (PROX>DIST) 5/5 4/5 (PROX>DIST) DEEP TENDON REFLEXES + ++ + ++ PLANTAR FLEXOR FLEXOR
Sensory system CORTICAL SENSATION - NORMAL ROMBERG'S – UNSTEADINESS BOTH EYES OPEN & CLOSED RIGHT LEFT UL LL UL LL PAIN NORMAL NORMAL TEMPERATURE NORMAL NORMAL TOUCH NORMAL NORMAL VIBRATION NORMAL NORMAL POSITION NORMAL NORMAL
Bilateral, symmetrical proximal > distal, flail weakness of lower limbs with intact reflexes, with gait ataxia, LMN type lower cranial nerve involvement without bladder or autonomic involvement of acute onset (over days).
CNS demyelination – ADEM/multiple sclerosis
Atypical viral encephalitis
Normal symptom Mitochondrial myopathy MS / ADEM Botulism Viral encephalitis Tick paralysis diphtheria Weakness Hemiparesis/ recurrent prox flaccid quadriparesis Pyramidal hemi/quadriparesis Flaccid quadriparesis, descending Focal, pyramidal Flaccid quadriparesis, ascending Flacid quadriparesis, descending Cranial nerves Only ocular Any cranial nerve Pupils, any cranial nerve Any cranial nerve Ocular, bulbar Any cranial nerve Ataxia +/- +/- - -/+ - - NCS Mild +/- + Characteristic finding not present in our case
ARAS, Respiratory center likely to be affected
Presence of tick
Neurological manifestation in proportion to pharyngeal
O/E alternating convergent squint +, Hirschberg test 15*
RIGHT LEFT EYE LIDS NORMAL NORMAL EYE LASHES NORMAL NORMAL CONJUCTIVA NORMAL NORMAL CORNEA CLEAR , SENSATION INTACT CLEAR, SENSATION INTACT IRIS COLOUR, PATTERN -NORMAL COLOUR, PATTERN -NORMAL PUPIL PUPIL 3mm, REACTING TO LIGHT PUPIL 3mm, REACTING TO LIGHT ANT CHAMBER NORMAL DEPTH NORMAL DEPTH LENS MINIMAL CHANGES MINIMAL CHANGES RETINOSCOPY +1.5/+1 +.5/+.5 EOM ABDUCTION RESTRICTED DEXTRO ELEVATION, DEXTRO DEPRESSION RESTRICTED LEVO ELEVATION, DEPRESSION NORMAL EOM – FULL