Case Study - The Drummer with Tingling Fingers
Aaron, a 26-year-old musician, visits his physician complaining of tingling in the fingers of his right hand. The feeling is present when he plays his drums as well as at other times of the day and night. Sometimes the tingling is so bad that he has difficulty feeling anything with his right hand and ends up dropping things. He has also noted that his right hand and arm get tired more easily than his left hand. In addition, he has had problems seeing correctly for the past 3 weeks; even during the day or in bright rooms, his overall vision is "darker" than normal. At times he feels like something is crawling over the right side of his face. Finally, Aaron mentions that during the time he has been most worried about these symptoms, his legs have felt weak and he has been tripping over things.
Examination reveals weakness of the rectus muscles of Aaron's right eye and mild weakness of his right facial muscles. Other muscles are of normal strength. Aaron exhibits normal reflexes, but his rightside reflexes are somewhat greater than those on his left side. The physician suggests that Aaron get more rest and have his eyes checked because he may need glasses. The physician also tells him to return if his condition does not improve.
Three months later, Aaron comes back. In addition to his previous symptoms, he has developed difficulty walking and speaking. Although he frequently feels the need to urinate, he is unable to fully empty his bladder. On this visit, the physical examination shows disturbances in Aaron's gait-he has become ataxic, and his stance is wider than normal. His superficial reflexes are diminished, and
his deep tendon reflexes are exaggerated. Based on these signs, the physician orders MRI scans and a spinal tap. The MRI results show areas of demyelination and plaques in the white matter of the brain. When the CSF is analyzed, elevated concentrations of leukocytes, protein, and antibodies are found, and myelin basic protein is present. These results lead to a diagnosis of multiple sclerosis.
Based on this case study and other information in this chapter, answer the following questions.
1. Why is multiple sclerosis not diagnosed initially?
2. How do Aaron's physical signs and symptoms support the diagnosis of multiple sclerosis? How could you rule out Guillain-Barré syndrome?
3. What treatments would you expect the physician to prescribe?
4. If you were Aaron's physical therapist and he asked your opinion of his prognosis, what would you tell him?
5. Why do plaques appear in the CNS of a patient with multiple sclerosis?
6. Suppose someone argued that the reason twins often share multiple sclerosis is not because it's hereditary, but because of some abnormality in the mother's pregnancy such as maternal exposure to a toxin or virus. What argument could you give against this hypothesis?
7. Autoantibodies are present in both Guillain-Barré syndrome and multiple sclerosis. Plasmapheresis is helpful in treating the former but not the latter. Explain this difference.
8. Are all gliomas malignant? Explain your answer.
9. Why are seizures a characteristic sign of gliomas?
10. Why are glial cells more likely than neurons to produce primary intracerebral tumors?