Yale Case Studies

Presentation of Case DR. Fox: A 44-year-old housewife entered the hospital on December 18. The present illness began eight months previously. Shortly after an attack of influenza and otitis media she began to notice burning and tingling in the fingers of the left hand. These sensations gradually spread up the left arm, across the shoulders and to the right upper arm. By September the pares-thesia was also present in the left leg, and, in the meantime, numbness and weakness had also made their appearance in all the extremities. At this time also the patient began to experience a tight feeling across the upper trunk and at times was short of breath. For three months prior to admission she was confined to bed because of increasing weakness and stiffness of the limbs. Recently she had become incontinent. Four lumbar punctures had been performed with negative results except for increased globulin. The patient failed to respond to various dietary regimes and physiotherapeutic measures. Physical Examination: The patient presented a diffuse but asymmetrical quadriplegia of a mixed flaccid and spastic type. There were signs of both upper and lower motor neurone degeneration. Atrophy of the upper limbs was marked, with fibrillary twitching around the shoulder girdles. The left arm was almost completely paralyzed and had presented a contraction deformity. The pyramidal signs in the lower limbs were well developed and at times the paraplegia assumed a flexion type. The sensory disorder had a definite upper segmental level at C 3 on the left and at C 5 on the right. The cutaneous area innervated by the cervical roots showed a definite dissociated anesthesia with loss of pain and temperature , but fairly good preservation of touch. There was also some impairment of sensation on the trunk and lower limbs. This was patchy and the response of the patient was variable. The disturbance seemed more marked on the left side of the body than on the right. Sensation over the sacral zone was intact. Vibratory sense was diminished over the spine below the fifth dorsal spinous process. There was some tenderness over the lower two cervical and upper three thoracic vertebrae. There was a bilateral Horner's syndrome, more marked on the right, with definite myosis, enophthalmos and droop of the upper lid. Respiration was almost entirely confined to action of the diaphragm and accessory muscles. The patient was incontinent of both urine and feces.