A 47-yr-old lady presented with monoplegia and progressive neurological findings and multiple co-morbidities

1. Presented by-
Dr. Jheelam Biswas
Resident, Phase A, Palliative Medicine
Orchid unit (Internal Medicine)

2.  Mrs. Rashida
 47 years
 Married
 Homemaker
 Hobiganj
 Admitted on 5/9/18

3.  Weakness of right upper limb for 2 weeks

4.  Weakness of right upper limb for 2 weeks which was-
 Sudden onset
 Started with tingling and numbness of fingers, then
gradually progressed over last 5 days to whole of the
right upper limb
 Not associated with pain or sensory loss
 No history of neck pain, trauma, headache, fever or
weakness of any other parts of her body.

5.  No difficulty in speech and swallowing
 No bowel or bladder involvement
 Non diabetic
 Normotensive
 She visited a local doctor who advised for NCS of
Rt. Median nerve and managed conservatively.
 As her condition did not improved, she was
referred to BSMMU.

6.  Pain and swelling of multiple joints for 4 years which-
-Involved MCP, PIP, wrists, elbow joints, ankle,
metatarso-phalangeal joints
-Bilateral symmetrical
-Inflammatory in nature
-Morning stiffness >1 hour
 She visited was labeled as a case of rheumatoid arthritis
on the basis of clinical criteria by local physician and
was given some medications that she could not
mention.

7.  She was on irregular medication and follow up.
 She visited an internist 1 year back and was put on
Methotrexate, Indomethacin and Deflazacort for 3
months.
 Her pain and swelling decreased.
 She developed dry cough and breathlessness 3
months after starting treatment.

8.  HRCT of chest was done and found to have B/L ILD
with bronchiactatic changes.
 Methotrixate was stopped.
 Currently she is on
- Salfasalazine
-Leflunomide for 1 year
 She is on remission for 1 year

9.  Tab. Salfasalazine (500mg)- 2+1+2
 Tab. Leflunomide (10mg)- 0+0+2

10.  Married for 22 years with no living child
 No family history of DM, HTN, RA, Br. Asthma
Obstetric and gynecological
history
 Menopausal for 3 years
 History of abortion at 12 weeks 10 years back

11.  She is from a lower middle class family
Immunization history
 Vaccinated with BCG vaccination

12.  Pulse- 78 b/min
 Bp- 110/80 mmHg
 Temp- 98F
 Resp. rate-16 b/min
 Swan neck deformity in Rt little finger, Lt index and
4th finger, lateral deviation of toes in Rt foot.
 No anemia, jaundice, cyanosis, edema, clubbing,
koilonichia, leuconychia, thyromegaly,
lymphandenopathy.

13.  Higher cerebral function- normal
 Cranial nerves- intact
 Motor system-
- Muscle power MRC grade 1in Rt upper limb
- Tone- reduced in Rt upper limb
- No wasting or fassiculation
- All jerks are normal.
-Planter- equivocal on Rt. side
 Sensory- intact
 Fundoscopy- Normal
 Signs of meningeal irritation- absent

14.  Hand
-Swan neck deformity in Rt little finger, Lt index
and 4th finger.
- No tender or swollen joints or Rheumatoid
nodules
 Foot - Lateral deviation of toes in Rt foot.
 Spine- Normal
 Gait- Normal

15.  B/L fine crepitation present in lower zone of both
lungs, more marked on Rt lung
 Not altered by cough

16.  Rheumatoid arthritis with DPLD with
monoplegia due to-
 Mononeuritis Multiplex
 Cervical myeloradiculopathy
 Acute stroke
 ICSOL

17. 25/5/2017 10/9/18
Hb 10.6 g/dl 13.4 g/dl
ESR 55 mm/1st hr 20 mm 1st hr
WBC 4500/ cumm 10800/cumm
MCV 78 fl 86.0fl
PBF Non specific findings

18. 25/5/17 6/9/18
Anti CCP antibody >200 U/ml (positive) 1108 U/ml
CRP 12 mg/L (positive) <3.2 mg/L (negative)
SGPT 17 U/L 20 U/l
S creatinine 0.8 mg/dl 0.69 mg/dl
RBS 5.8 mmol/L 6.4 mmol/l
S. electrolyte Na- 136 mmol/l
K- 3.7 MMOL/L
Urine R/E PC-10-15 HPF
Anti phospholipid Ab negative

19. Fine
reticulonodular
shadow in lower
zone of rt. lung

21.  Suggestive of B/L interstitial lung disease
with bronchiectatic change, more marked in
lower lobes of both lungs.

22. • Cervical lordosis
straightened
• Osteophyte in C5,
C6 level
• Rudimentary
cervical rib on left
side

25.  T1W1 shows mixed signal intensity mass
(3.5*2.7*3.3 cm) in left parietal region.
 On contrast thick irregular rim enhancement with
central interlesional necrosis.
 Huge perifocal edema seen in T2 film.
 3rd and left lateral ventricles are compressed by
the tumor.
 Impression: ICSOL in left parietal region, possibly
Glioblastoma Multiforme.

26.  ICSOL in left parietal region with RA with
DPLD.