Interesting MRI--Difficult Case

by

Eric Awad, M.D.

I will try to make this very brief. a 31 y/o woman who is a recovering alcoholic ( up to 12 beers a day for 5 years, nothing else at all ) presented with resolving bulbar symptoms and signs. She also has very painful feet, NCS showed mild sensorimotor neuropathy. EMG is negative. Painful feet are not responding to anything. No malingering or hysterical stuff. No drug seeking. No PMH at all, never used drugs. Smoker up to recently. No family history of neurological disease.

The MRI ( i have never seen anything like this before, neither have our neuroradiologists): Beautifully symmetric areas of high signal intensities involving the basal ganglia (on the FLAIR and T2 WI), globus pallidus, medial aspect of the thalami, midbrain, cerebral peduncles, posterior aspect of the basal ganglia just lateral to the GP, maybe also involving the external capsule. These lesions are so symmetric, they are an exact copy of each other. Not a millimeter of difference at all. No enhancement, no edema, no shifts. Basic and nutritional labs, connective tissue work up, all B vitamin family, urine and blood drug screens, heavy metals are normal. CSF was done yesterday, normal pressure. Clear CSF, I do not have the results yet ( i know, i should of waited, i will give them ASAP).

She is back to normal except for severe pain in both feet with discoloration to red, she is unable to walk from the pain. Exam is normal otherwise. No long tract signs. This is beyond me, and beyond everyone i asked. i am sending her to the Mayo clinic in Jacksonville, Florida. her parents live there. I do not know anyone there who is a specialist in such demyelination. Any other ideas? and if you know any neurologist who can handle this, at the Mayo Clinic in Florida, please, let me know. its gonna turn out to be a metabolic/toxic problem. its just that it does not fit any of the patterns i know. i wish i could post her MRI on line.

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Submitted August 7, 2000

(c) 2000 Medical College of Georgia