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Case History
A 66-year-old woman presented to urgent care with progressive neurologic symptoms over the previous week. Her symptoms started with a pins and needles sensation in her chest. Over the next few days, bilateral leg weakness developed and she noted worsening vision and bladder control.
On initial examination, she was alert and well-oriented. Pertinent physical findings included normal vital signs; normal chest, heart, and abdominal examination; and no evidence of trauma. Visual field testing showed large central scotomas bilaterally. Pupils were 3 mm on the left and 5 mm on the right, with an afferent pupillary defect on the right. Other cranial nerves were intact. Motor, reflex, sensory, and cerebellar examinations of the upper limbs were normal. In the lower limbs, strength was 2/5 in all groups tested. Knee jerks were 4+ bilaterally and ankle jerks were 4+ bilaterally, with sustained clonus. Bilateral Babinski signs were present. There was a sensory level at T4.
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