Hospital Course and Physical Exam
The patient was treated for "transverse myelitis" with oral prednisone and experienced initial improvement. However, he soon developed mental status changes prompting a repeat MRI of the brain that now read as "abnormal." The patient was then transferred to Johns Hopkins Hospital, Baltimore, Maryland. for further work-up. He was initially found to be afebrile, with stable vital signs.
The patient was alert and oriented to person, but with a flat affect and complaining, "Takes an eternity to answer questions." His speech was slow but fluent, and language comprehension intact, but he had difficulty with complex tasks.
His pupils were equal, round, and reactive; he was unable to cooperate with the visual field exam. Extraocular movements were full but, again, he was unable to complete pursuit testing. His facial movements were symmetric and sensation was intact. His tongue and uvula were midline. The exam demonstrated left-sided sensorineural hearing loss. Sternocleidomastoid and trapezius muscle strength were normal.
Deep tendon reflexes:
His head MRI was repeated and is shown in Figure 1.
Diffusion-weighted and fluid-attenuated inversion recovery (FLAIR) sequences demonstrating multiple active ischemic lesions.
Which of the following tests should be done first?
Temporal artery biopsy
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Cite this: Case 7: Chief Complaint: Paraplegia and Encephalopathy - Medscape - Dec 15, 2004.