An unusual case of hemiparesis in a young woman

Abstract

A 41-year-old woman, previously fit and well, was admitted with acute onset of left-sided weakness and unsteadiness. Apart from a week-long history of dizziness preceding admission, there was no other history of note. Clinical examination revealed a mild left hemiparesis, left upper motor neuron facial weakness and an ataxic highstepping gait. There was also evidence of left past-pointing and dysarthria. Sensation and proprioception were intact. Eye examination was normal and fundoscopy did not show papilloedema. A large partially healed ulcer was noted on the patient’s lower lip and several smaller ulcers at different stages of healing were also noted on the vulva. A small cluster of pustules were seen over the left cheek. The remainder of the clinical examination was normal. Blood tests showed a mild normochromic normocytic anaemia (haemoglobin 10.5 g dl) but electrolytes and liver function tests were within normal limits and the erythrocyte sedimentation rate was not significantly raised (15 mm h). A chest radiograph revealed no significant abnormality and likewise urine culture was unremarkable. The patient was referred for MR imaging of the brain. An axial fluid-attenuated inversion-recovery (FLAIR) image (Figure 1) through the mid-brain at the level of the inferior colliculi and an axial T2 weighted image (Figure 2) through the mid-brain at the level of the superior colliculi and red nuclei are shown. An axial T1 weighted image following intravenous contrast administration (Figure 3) is shown at the same level as in Figure 2. Lumbar puncture was performed after the MR scan. This revealed a mildly elevated protein in the cerebrospinal fluid (CSF).