A 37 years old female suffered from multiple traumas caused by road accident with admittance to emergency room- multiple contusions, cervicalgia(due to whiplash) and contusion-laceration injury to left knee. An MRI scan of the knee was performed two months later (MRI findings are attached below) and the patient was examined by a specialist who gave a diagnosis of medial meniscal tear and femur-kneecap pain in the left knee. A broken medial meniscus of the left knee diagnosis should lead to an arthroscopic operation.
71-year-old female developed progressive dysarthria and dysphagia. Her doctor describes her speech difficulty as “Spastic dysarthria with slow and nasal speech" and noticed decreased mobility in the tongue and palate. She underwent multiple investigations and started Rilutek. The differential diagnosis of isolated swallowing and speaking difficulties include: Early motor neuron disease, Cranial neuropathies, Myopathies, Neuromuscular junction disorders and Neurodegenerative movement disorders.
The patient, 43 year old, used to be very physically active and carry a large amount of equipment on him.
41 year-old male was recently diagnosed as having multiple sclerosis (MS) after episodes of leg and shoulder weakness and parasthesis. Lately he experiences dizziness. His MRI showed several demyelinating lesions, other ancillary tests showed demyelinating damage to the auditory and visual pathway. Currently he has no functional or sensorial deficiencies. He was offered several immunomodulatory treatment options: Rebif, Betaferon and Copaxone, and asks about their pros, cons and complications, and about the differential diagnosis.
71-year-old female developed progressive dysarthria and dysphagia. She underwent multiple investigations and started Rilutek. Her EMG study does not meet published criteria for the electrophysiologic diagnosis of motor neuron disease. In the expert's opinion, a definite diagnosis is not possible at the present time, and there would be utility in repeating clinical and electrophysiologic testing. The expert also recommends to perform pulmonary function testing.
39-year-old male experienced in 1994 intense lower back pain after lifting weights, with spontaneous resolution. In 2006, he again experienced lower back pain radiating into both thighs. A lumbar MRI showed degenerative changes and EMG test showed L5 nerve root irritation. His physical examination demonstrated increased reflexes and a concern for cervical stenosis was entertained. Further cervical MRI and lumbar studies showed arthritic changes, and the thoracic MRI showed evidence of spinal cord compression. The surgeon suggested posterior thoracic laminectomy.
25-year-old male had an outbreak of sharp pain in the loin, and afterwards complained of partial sensory anesthesia in his leg. He has been given prescribed treatment that included blockades, magnetotherapy, and ultrasound massage with hydrocortison. He experienced back pain for the first time after lifting a heavy thing, and got a pain relief after taking a pain-killer and applying Finalgon ointment. After few months the pain reoccurred. The patient then got a MRT test and was prescribed Finalgon and Milgamma pills, but developed an allergy towards Milgamma.
A 61 year old male who presented with an epileptic episode was evaluated. A temporo-parietal-occipito mass was detected on MRI and PET CT. A follow-up MRI one year later showed progression of the lesion. One month later he had a craniotomy and what seems to be a partial removel of the mass. The pathology revealed glioblastoma. He was scheduled for radiotherapy two months later. The post operative MRI showed post operative changes including blood at the surgical cavity. However, there is a significant residual tumor present which is enhancing following administration of contrast.
72-year-old female developed progressive dysarthria and dysphagia. Her doctor describes her speech difficulty as “Spastic dysarthria with slow and nasal speech" and noticed decreased mobility in the tongue and palate. She underwent multiple investigations and started Rilutek. Since there is no biologic marker for ALS, the expert suggests further testing that is focused on trying to rule out other disorders and show diffuse lower motor neuron involvement
Child with progressive exotropia secondary to the profound vision loss that appears to be to an optic neuropathy. The expert recommends to obtain additional studies in order to exclude potential diagnosis such as glioma, pathological disc edema, optic nerve drusen or dominant optic atrophy OPA-1 gene related.
7-year-old boy with prodrome of right-sided and right face weakness, gait ataxia, and intermittent headaches. Head computed tomography demonstrated a tumor at the brainstem/posterior fossa, and then MRI confirmed a diffuse intrinsic pontine glioma (a typical brainstem glioma). Following initiation of dexamethasone (Decadron, steroid for vasogenic edema), the child has started experimental treatment with the medicine nimotuzumab to be followed with conventional radiotherapy.
66-year-old male with a 6-year history of sensory symptoms in the feet and hands. He describes a sensation of cold and stinging in the feet; and numbness in the hands, especially at night. Nerve conduction and EMG demonstrated axonal and demyelinative sensorimotor neuropathy with neurogenic changes in muscles. Follow-up nerve conduction testing that was performed 2 years later showed similar findings.
23-year-old female had episodes of hemiparesis, dysmetria and parenthesis underwent MRI that showed a demyelization process. After she was hospitalized with Left Retro-Bulbar Optic Neuritis, she started treatment with weekly injections of AVONEX (Interferon beta-1a). Now she is in good general health and asks about stopping the Anovex treatment. The expert answers that she shouldn't stop the treatment , because the purpose of the medications is to prevent exacerbations, that may leave neurologic residual dysfunction.
A 23 year old female was diagnosed 7 years ago with multiple sclerosis. The patient had 4 acute attacks 7 years ago, and since then she has been treated by Avonex. The patient had no attacks since then, feel healthy and lead a normal healthy life as a busy university student. She enjoys sports several times a week, and there are no problems regarding her physical and mental function. Neurologically, the only reminiscence of her illness is a positive Babinsky sign in the left leg and a temporal blindness in the left eye.
55-year-old female was diagnosed with glioblastoma after suffering increasing headaches, and was treated with radiation with concurrent Temodal. MRI exam that was performed after 2 additional cycles of CCNU showed tumor progression. The expert recommends different further treatment options.
21-year-old female with an acute onset of a unilateral sixth cranial nerve deficit. Brain MRI showed at least a dozen white matter lesions, one of them contrast-enhancing. Sensory evoked potentials showed a bilateral increase in latency. Multiple sclerosis was diagnosed, and the patient was treated by corticosteroids, followed by improvement of symptoms. The first follow-up revealed no focal neurological signs with a history of a transitory unilateral lower limb hyposthenia. On the second visit, a horizonto-rotatory nystagmus and irregular paraesthesia in the right toes are documented.
67-year-old male began to complain of chronic pain in the left lower rib cage. The pain is stitch, ever-present, dull and localized at the level of his left last rib, and became slightly worse in the last 2 years. Recent image findings: MRI - "Ovalish hypoechogenic solid formation, Ultra sound - "Suspected intercostal neurinoma at ribs 10, 11 and 12.
47-year-old male has injured his right wrist while playing football 30 years ago. He always had some manageable pain while playing tennis. The pain increased during the last 12 months, and following this, MRI studies were performed. They revealed wrist Diastasis between scaphoid and semilunar bone in agreement with a lesion of the scapholunate ligament and pronounced radioscaphoid arthrotic manifestations. In the expert's opinion, the patient is suffering from post traumatic osteoarthritis of radio-carpal joint brought upon by ligamentous injuries due to trauma.
52-year-old male with a one year history of lower motor neuropathy affecting the limbs, left upper and lower limbs clinically and all 4 limbs electrically. The neurologic examination showed left lower and left upper limb hyposthenia with mainly distal motor clumsiness, appearance of left upper limb hypotrophy and diffuse fasciculations. The patient was diagnosed with “suspect motor neuron disease" and was treated with IVIG cycles with slight initial improvement, but later lack of response and worsening of the clinical condition.
47-year-old female who had the onset of persistent vertigo. The first evaluations revealed right beating nystagmus on gaze straight and to the right, unsteady gait with limb ataxia, and positive head thrust to the left. Improvement seemed to be occurring in that gait deviation with eyes closed was no longer present. Vestibular physical therapy exercises were started. On the next evaluations there was paroxysmal positional vertigo from the left ear and minimal neurosensory hearing loss. An audiogram showed minor neurosensory deafness.
A 66 year old man that was diagnosed with prostate cancer underwent radical prostatectomy 2 years ago. Pathology result of the surgical specimen revealed poorly differentiated prostate carcinoma with positive surgical margins. He was treated with antiandrogens and adjuvant radiation therapy. Since the beginning of the last year and under hormonal monotherapy with Casodex his PSA levels doubled. PET CT of the abdomen and the pelvis revealed hepatic lesion.
41-year-old male that in the past decade had suffered 2-3 times a year from bilateral knee pain which resolved spontaneously. Last year he had episodes of thumb pain that had lasted for several weeks and had affected grasp movements. The patient had responded to NSAID treatment for 2 weeks. MRI of the right knee showed Mild endoarticular effusion in the sub-quadriceps recess, chondropathy of the femoropatellar joint and lesion of the medial meniscus.
53-year-old male with lower motor neuropathy affecting all 4 limbs. The neurologic examination showed left limb hyposthenia, left upper limb hypotrophy and diffuse fasciculations. The patient was diagnosed with “suspect motor neuron disease" and was treated with IVIG cycles with slight initial improvement, but later lack of response and worsening of the clinical condition.
36-year-old otherwise healthy female presented with an atypical pap smear. Biopsy of cervix revealed poorly Differentiated Neuroendocrine Carcinoma. Immunohistochemical staining showed the cells positive for NSE, SYN, CHR, and 90% positive for Ki67 (proliferative index). The findings of the PET-FDG test showed pathological absorption of FDG as a primary tumor of the cervix, towards the left side of the body. Moreover, evidence is seen of nodal metastatic spread in the retroperitoneum and pelvis, mainly on the left.
47-year-old male has injured his right wrist while playing football 30 years ago. He always had some manageable pain while playing tennis. The pain increased during the last 12 months. The wrist CT scan that the expert recommended revealed diastasis between scaphoid and semilunar bone, palmar dislocation, dorsal intercalated segmental instability (DISI), marked radio-scaphoid arthritis and reactive sclerosis of the subchondral bone. This findings conformed the previous diagnosis of post traumatic osteoarthritis of radio-carpal joint brought upon by ligamentous injuries due to trauma.
A 58 years old male. 4 years ago the patient was hospitalized due to acute thrombosis of the right femoral-iliac axis. The patient was treated succesfully with locoregional intra-arterial fibrinolytic therapy. A follow-up arteriography, revealed sub-occlusion of the common iliac, occlusion of the right superficial femoral artery in Hunter’s canal. PTA + stent of the iliac was carried out with excellent final angiographic result.
65-year-old female that suffers from pain in the left knee underwent examinations that showed femoral-tibial arthrotic manifestations, external degenerative meniscal tear and moderate joint effusion. A diagnosis of external degenerative meniscal tear was established. Further medical tests showed marked degeneration of the meniscal fibrocartilage, diffuse femoral-tibial arthrotic abnormalities, subchondral cysts and edema of the spongious bone, as well as rarefaction of the cartilage matrix, and manifestations of chondropathy.
74-year-old female suffers from recurrent episodes of paroxysmal atrial fibrillation (PAF) and has been recommended oral anti-coagulant therapy with warfarin (Coumadin). She has mitral regurgitation, and on the other hand was diagnosed as suffering from congenital bronchiectasis with several episodes of significant bleeding (hemoptysis). Following these hemoptoic episodes she underwent series of diagnostic as well as therapeutic pulmonary intervention (bronchoscopy, angiography, embolization).
The patient is a 21 month old female who was born prematurely (at almost 29 weeks) weighing only 650g. She was released after 3 months from NICU, when she was 41 weeks old, weight 2kg. Her parents did not have any problems till she was 5 months old. Her major problems since have been: poor feeding, failure to gain weight and linear growth retardation. The poor feeding has been handled by an NG tube and later, food administration through a direct gastric tube via a gastrostomy.
21-month-old female who was born at almost 29 weeks weighing only 650g and with birth height of 31 cm. Her major problems have been poor feeding, failure to gain weight and linear growth retardation. The poor feeding has been handled by an NG tube and subsequently, food administration through a direct gastric tube via a gastrostomy. She gradually gained weight to the extent of being overweight for her height. Laboratory evaluation revealed low absolute numbers of neutrophils low lymphocyte count. Endocrynology and Genetics workup were normal.
70-year-old female with a history of diabetes mellitus began experiencing pain in the legs. In the last few months the pain localized in her inner thighs. It is burning in nature, with sudden intense attacks, and is consistent with neuropathic pain with neuralgic features. The expert suggests possible diagnosis, further investigation and symptomatic treatment. In his opinion, it is likely that the cause of the symptoms is peripheral neuropathy or radiculopathy.
27-year-old female with a diagnosis of suspected fibromyalgia. Her history includes long standing widespread musculo – skeletal pain connected to a feeling of general slight illness, as well as a series of accompanying symptoms: frequent migraines, cervicalgia, stomach disorders, chest pain and tachycardia . Therefore, she has carried out various follow-ups that each time detected a different problem for which the relevant therapy was set out.
