A 66-Year-Old Woman with a Progressive, Longitudinally Extensive, Tract Specific, Myelopathy
Table 1
Relevant data.
Plasma/serum/urine
Vitamin B12 (211–911 pg/mL)
524 pg/mL
Methylmalonic acid (≤0.40 nmol/L)
0.31 nmol/L
Homocysteine (5–15 µmol/L)
11.7 µmol/L
Vitamin E (5.5–17.0 mg/L)
17.7 mg/L
TSH (0.35–5.50 mcIU/mL)
1.07 mcIUnits/mL
Free T4 (0.9–1.8 ng/dL)
1.12 ng/dL
β2-Microglobulin (1.1–2.5 mg/L)
4.4 mg/L
ANA, ANCA, anti-dsDNA, ENA
Negative
24-hour urine heavy metals (mercury, lead, arsenic)
Negative
24-hour urine zinc (300–600 mcg/24 h)
909 mcg/24 hr
24-hour urine copper (15–60 mcg/24 h)
22 mcg/24 hr
Serum paraneoplastic panel
0.03 and 0.04 nmol/L
Negative except for calcium channel ab N-type (<0.03)
Pathology
CSF cytology
Negative
Fine needle aspiration of right paratracheal lymph node
Negative
Skin biopsy
Negative for lymphoma
Quadriceps biopsy
Negative for lymphoma
Microbiology
HIV
Negative
HTLV-1
Negative
RPR
Negative
Mycobacteria (AFB) culture and acid fast stain
Negative
PPD
Negative
Blood cultures
Negative
Urine cultures
Negative
Respiratory cultures from bronchoalveolar lavage
Negative
CSF culture × 2
Negative
Fungal culture of blood
Negative
CSF
Jun 14
Aug 14
Glucose
113 mg/dL
120 mg/dL
Protein (15–45 mg/dl)
30 mg/dL
41 mg/dL
Nucleated cells (cells/µL)
0
0
Red blood cells
0
0
CSF IgG index (≤0.85)
0.6
0.62
CSF specific oligoclonal bands
0
0
CSF paraneoplastic panel
Negative
CSF cytology
Electromyography (EMG)/ nerve conduction study
Length-dependent sensorimotor axonal polyneuropathy with small sural sensory nerve action potential amplitudes and EMG evidence of subacute and chronic neurogenic changes limited to a distal leg muscle.
TSH, thyroid stimulating hormone; HIV, human immunodeficiency virus; HTLV, human T-lymphotropic virus; RPR, rapid plasma reagin; ANA, anti-nuclear antibody; ANCA, anti-neutrophil cytoplasmic antibody; dsDNA, double-stranded DNA; ENA, extractable nuclear antigen. Paraneoplastic panel: antistriated muscle; antiacetylcholine receptor (ganglionic neuronal); anti-voltage-gated calcium channel binding P/Q type; CRMP-5 IgG; antineuronal nuclear 1, 2, 3; Purkinje cell cytoplasmic types 1 and 2 and TR; amphiphysin, antiglial nuclear; antineuronal voltage-gated potassium channel; and anti-GAD65 antibodies. CSF panel tested with indirect immunofluorescence assay and serum panel tested with indirect immunofluorescence assay and radioimmunoassay (RIA) [12].
