1. A 21-year-old female presented with progressive weakness on the right side of her body over 1.5 years, along with fever, headache, diplopia, and two seizures. 2. Neurological examination revealed spastic right hemiparesis, internuclear ophthalmoplegia, nystagmus, and ataxic gait. 3. MRI brain showed multiple enhancing lesions in the midbrain, left periventricular area, and left basal ganglia, suggestive of tuberculomas. She was diagnosed with multiple tuberculomas and treated with anti-tuberculosis therapy and steroids.

1. CLINICAL CASE PRESENTATION
BY
DR.IMTIAZ AHMAD
PGR.WMW

2. HISTORY
Patient hina D/O M.abid,
unmarried female 21,resident of
BILAL GANJ LAHORE, working as
beautician in parlor presented
to us in OPD with the
complaints of:-

3. Presenting complaint
• Weakness of Rt. side of the body…… 1.5years
• Incoordination between eyes……..1year
• Fever…………………………………………..1year

4. HISTORY OF PRESENTING COMPLAINTS
• Patient was in usual state of heath 1.5 years ago
when she started pain and numbness in her Rt.
Hand.pain was diffuse in whole hand, moderate
in intensity, crampy in nature, without any
swelling and deformity.
• No history of trauma.
• Over the next 15 days patient got the same pain
and numbness in her Rt. Arm, with additional
complaints of loss of power in her Rt. arm.

5. • Patient took medication form local GP. And hekeem but
symptoms persisted.
• Over the next 3 months these symptoms worsed, pain
at all the times. She had to take pain killers multiple
time per day.
• Pain and weakness developed in Rt. lower limb over
the period of 6 months. She was having mild difficulty
in carrying out her routine activities,
• There is history of repeated fall due reduced power in
Rt. side of the body.
• Weakness was gradually progressive.
• There is history of speech abnormality.

6. • About one year ago she started having fever, that
was low grade, continuous, at all the time, not
associated with rigor and chills. Relieved only by
medication, it was associated with headache, that
patient could not localize.
• Fever was not associated with vomiting, diarrhea,
burning micturition, ear and nasal discharge.
• There is nonspecific history of cough and sputum
to which patient did not give any attention.
• History is suggestive of loss of apatite and
significant weight loss ( 5-8 kg in 6months)

7. • 1 year ago she noticed double vision and
dropping of Rt. Eyelid, it was progressive over 20
days after which it got static. It was not
associated with impairment in vision. Mother
noticed that her Rt. Eye was deviated outward.
• She was not a known case of having squint.
• She was an obese girl before this whole ailment ,
no history of excessive body hair, menstrual
irregularities and oral contraceptive intake.

8. • 1 month after fever and diplopia she got 2
episodes of complex partial tonic clonic fits on Rt.
side of the body In 15 days. Each time fits were
about 5 mints duration, without tongue bite ,
fecal and urine incontinence.
• Few days after the seizures she got complete loss
of power on Rt. side of body, with fecal and urine
incontinence and impaired conscious level.
• All the neurological deficit was gradually
progressive without any remission.

9. PAST HISTORY
• No history of weakness in past.
• No past history of epilepsy.
• No history of tuberculosis.
• No history of bleeding diathesis
• No history of head trauma.
• No past history of any acute visual loss
• No past history of admission and any intervention
in the hospital.
• No history of arthritis and rash.
• No history of pain or swelling in the spine.

10. PERSONAL HISTORY
• Unmarried sexually inactive female with
regular menstrual cycle.
• Non addict non smoker
• Working as beautician in her congested house
in a densely populated area.
• No history of foreign travel.
• Normal sleep and bowel habits.

11. DRUG HISTORY
• NO history of drug abuse
• She received proper immunization according
to EPI. Program
• No history drug allergy.

12. SOCIO-ECONOMIC HISTORY
• Poor family.
• Living in small apartment with six siblings and
parents.
• Tuberculosis is common disease in the area
she lives
• Good relation with kith and kin,

13. FAMILY HISTORY
• No family history of infectious diseases.
• history of hypertension and diabetes mellitus
& IHD positive in family.
• No family history of disabling disease.
• No family history of epilepsy.

14. SYSTEMIC REVIEW.
• No history of palpitation, SOB, pedal swelling
• No history of hemoptysis and hematemesis
• No history of joint pain and rash
• No history of vomiting, abdominal pain,
distention, diarrhea, burning micturition and
pus in urine
• No history of oral and genital ulcers

15. summray
• A young girl got progressive weakness of rt. side of
body, two episodes of fits, diplopia ,scanned speech
and incoordination in a setting of low grade fever and
headache over the period of 1.5 years.
• Progressive neurological deficit that she attained never
remitted except for improvement in diplopia, eyes
coordination & autonomic improvement.
• She is not known epileptic, no history of head trauma,
ear and nasal discharge, bleeding diatheses, oral ulcers,
skin rash, joint pain,
• Signs of meningeal irritation remained absent through
out the course of disease

16. DIFFERENTIALS ????

17. GENERAL PHYSICAL EXAMINATION
• A young girl of average height and built,
having deformed Rt. side of body, lying
comfortably in bed, Well oriented with time
space and person. Having vitals:
• Pulse : 90/ mnt
BP: 100/70
• TEMP: 99 F
• R/R: 20/ mnt

20. Pallor, cynosis, clubbing, jaundice, edema,
lymphadenpathy ………………………. Absent
JVP….. Not raised
Thyroid not enlarged.

21. CNS
• HIGHER MENTAL FUNCTIONS……….. INTACT
• EXCEPT SCANNED SPEECH …++VE
• CRANIAL NERVES: Right Left
• olfactory: intact intact
• Optic intact intact
• Occulomotor palsy palsy
• Trochlear intact intact
• Trigeminal intact intact
• Abducent paresis ntact.
Rest of all the cranial nerves were intact.
INFERANCE: internuclear ophthalmoplegia--- one and half
syndrome.( lesion in dorsal pons)

27. D/D of incoordinant eyes
Deviated in primary gaze
1. False localizing sign.
2. Paralytic squint
Deviated on movement
1. internuclear
ophthalmoplegia
2. Latent squint.

31. CNS
MOTOR SYSTEM:
Rt. Arm has flexion contracture at elbow, wrist and small joints
of hand.
Rt. side of body less mobile.
No visible fasciculation's and fibrillations.
Right Left.
Tone: clasp knife slightly inc.
Bulk: reduced normal
Power: 2/5 5/5
Reflexes: brisk normal
Ankle clonus +++ -
Planters up down

39. CNS
• SENSORY SYSTEM:
• All the sensations are intact no sensory level.
• CEREBELLUM:
• Nystgmus ++
• Scanned speech ++
• No coordination. more marked on right side
• Ataxic spastic gait.
• AUTOMONIC:
• no fecal and urine incontinence or retention at present,
• Sign’s of meningeal irritation: absent
• FUNDOSCOPY: NORMAL.

41. CVS; NORMAL
RESPIRATION: NORMAL
GIT: NORMAL
BREAST EXAMINTIION NORMAL
SKIN AND JOINTS EXAMINATION NORMAL

42. CASE SUMMARY
• A young girl got progressive weakness of rt. side of body, two
episodes of fits, diplopia ,scanned speech and incoordination in a
setting of low grade fever and headache over the period of 1.5
years.
• Progressive neurological deficit that she attained never remitted
except for improvement in diplopia, eyes coordination & autonomic
improvement.
• She is not known epileptic, no history of head trauma, ear and nasal
discharge, bleeding diatheses, oral ulcers, skin rash, joint pain,
• Signs of meningeal irritation remained absent through out the
course of disease
• On examination: she had spastic rt. hemiparesis,with out sensory
level, internuclear ophthmoplega, nystagmus and ataxic gait.

43. Differential diagnosis
1. Multiple sclerosis
2. Tuberculous encephalitis with
multifocal tuberculomas
3. Primary or Metastatic brain tumor
4. Vasculitis with multifocal infarcts
5. Multisystem atrophy

44. INVESTIGATIONS
• CBC: normal
• TLC: normal
• DLC: normal
• ESR: 100-7040/mnt.
• C-Reactive protiens: negative
• LFT’s : normal
• RFT’s : normal
• S/E : normal
• Sr. CALCIUM: 8.1mg/dl ( 8.5-10.5)
• Phosphorous: 5.1mg/dl (2.5-5.0)
• ALK.po4: 132 (90-295)
• BSL: normal

45. • ANA : -VE
• Anti DS DNS: -ve
• RA factor: -ve
• Blood cultures –ve
• sr.Homocystein level normal
• LUMBAR PUNCTURE: they refused
at all the occasions. So not done

46. • CHEST X-RAYS : NORMAL
• ECG: NORMAL

47. CT-BRAIN (PLAIN)

49. CT-BRAIN WITH CONTRAST

51. MRI BRAIN

54. MRI report
• Multiple enhancing leisions are noted in
midbrain, left periventricular area and left
basal ganglia with disproportional perileisional
edema, compressing the third ventricle. Mild
non-communicating hydrocephalus.

55. D/D of midbrain and basal ganglia
enhancing lesions
1. Tuberculomas
2. Willson’ s disease
3. Tuberous sclerosis( sub-ependymal
calcifications)
4. Hypoparathyroidism
5. Toxoplasmosis
6. Mitochondrial diseases.
7. CNS lymphoma after radiotherapy

56. • NERVE CONDUCTION STUDY: NORMAL
• EMG: NORMAL

57. • KF.ring: -ve
• 24hour urinary protien: 197ug
(10-100)
• Sr.ceruloplasmin level: 27mg/dl
(15-60)
• Sr. PTH: 11.70pg/ml (10-65)

58. Final diagnosis
• MULTIPLE TUBERCULOMAS IN MIDBRAIN,
LEFT PERIVENTRICULAR AND BASAL GANGLIA
AREA
• Associated with arachenoiditis of cord.

59. TREATMENT
• ANTI- TUBERCULOUS THERAPY
• STEROIDS: for 4 to 6 months.
• MANITOL.
• DURATION OF THERAPY:
• ATT. SHOULD BE CONTINUED TILL THE
TUBERCULOMA RESOLVE ON REPEATED MRI.