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A woman developed blurred vision in the left eye at age 20 years, clearing after one week without treatment.  Two years later, she noted diplopia, not present when she closed either eye and clearing after forty-eight hours without treatment.  At age 30 years, she was admitted to the hospital because of progressive weakness in the left leg of 24 hours duration.  Family history was negative.

Neurological examination on admission showed the following abnormalities: she was unable to walk because of weakness of proximal and distal muscles of the left leg.  Both legs, but particularly the left, were spastic, with bilateral ankle clonus and bilaterally positive Babinski responses.  Position sense was impaired in the left foot, and there was diminished perception of painful and thermal stimuli on the right side of the body up to theT10 dermatome.  There was no horizontal nystagmus on lateral gaze to either side, and the left optic disc was pale. Visual acuity was normal on the left, but a left relative afferent pupillary defect was present.  The remainder of the neurological examination was within normal limits. 

QUESTIONS:  CASE SUMMARY 6

1.      What parts of her nervous system had been affected by her disease (by history and by physical examination)?

2.      Describe the most likely pathology, pick the most likely diagnosis, and suggest laboratory tests that might help to confirm the diagnosis?

3.      Discuss the geographic, immunological and genetic factors that seem important in genesis of this neurological disease.

4.      What findings would you expect to find on magnetic resonance imaging of the brain?