An elderly Male presented with bilateral ptosis & diagnosed finally as Brain stem Meningitis.

1. Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM

2. A 56 years old diabetic right handed gentleman,
hailing from Gazipur, got admitted in BIRDEM
General Hospital on 10th October,14 with the
complaints of-
• Drooping of eyelid for 2 months
• Headache for 3 months

3. According to the statement of the patient, he
was reasonably well 3 monthsback. Then he
developed headache which was gradual on
onset, global, dull aching in nature, mild in
severity. It was not associated with radiation,
vomiting, eye ache, exaggerated at morning
& coughing. It was relieved with medication.

4. H/O Present illness
He also has complaints of drooping of both
eyelid which was gradual on onset,
asymmetrical, double vision, eye ache. On
detailed query he gives h/o fever for 3
months which was low grade, intermitted,
associated with generalized weakness. It was
not associated with chill & rigor, night
sweating, diurnal variation, cough, weight
loss.

5. H/O Present illness
With the above complaints, he visited
opthalmologist & neurologist outside BIRDEM
& investigated. He was diagnosed as bilateral
opthalmoplegia due to mononeuritis multiplex
due to diabetes mellitus. He was referred to
Neurology, BIRDEM for further investigation
& management.

6. CT Scan of Brain

7. CT Scan of Brain

8. H/O past illness:
Nothing contributory
Socioeconomic history:
He belongs to a middle class family
Personal history:
He is non alcoholic, non smoker

9. Family history:
Nothing significant
Treatment history:
Tab. Glimiperide
Tab. Vit B complex

10. General examination:
Appearance: ill looking, bilateral ptosis
Built: average
Decubitus: on choice
Anaemia
Jaundice
Cyanosis
Oedema
Dehydration
Clubbing
Koilonychia
Leukonychia
Absent

12. General examination:
Neck vein: not engorged
Thyroid: not enlarged
Lymph node: not palpable
Skin pigmentation & body hair distribution: normal
Pulse: 86 b/min
BP: 130/80 mmHg
Temp:98 F
RR: 16 breaths/min

13. • Higher psychic function : Conscious, Oriented
• Speech: Normal
• Cranial nerves :
Complete opthalmoplegia on right eye
3rd
, 4th
& partial 6th
nerve palsy on left eye
• Fundus: Normal
• GCS: 15/15
NERVOUS SYSTEM EXAMINATION

14. Video clips

16. Muscle Rt. UL Lt. UL Rt. LL Lt. LL
Bulk Normal Normal Normal Normal
Tone Normal Normal Normal Normal
Power Normal Normal Normal Normal
Involuntary
movement
Absent Absent Absent Absent
MOTOR FUNCTION:

17. Reflex B T S K A Abd Plantar
Right ↑↑ ↑↑ ↑↑ ↑↑ ↑↑ Present Flexor
Left ↑↑ ↑↑ ↑↑ ↑↑ ↑↑
Present
Flexor

18. Sensory system:
Pain Temp Touch Vibratio
n
Position
sense
Right upper
limb
Intact
Right lower
limb
Left upper
limb
Left lower
limb

19. • Sign of Meningeal irritation - Absent
• Cerebellar sign : Absent
• Gait: Absent

20. Systemic examinations
Other systemic examination was normal

21. A 56 years old gentleman hailing from
Gazipur got admitted in Neurology with the
complaints of headache which was gradual
on onset, global, dull aching in nature, mild
in severity. It was not associated with
radiation, vomiting, eye ache, exaggerated at
morning & coughing.
Salient feature

22. Salient feature
He also has complaints of drooping of both
eyelid which was gradual on onset,
asymmetrical, double vision, eye ache. On
detailed query he gives h/o fever for 3 months
which was low grade, intermitted, associated
with generalized weakness. It was not
associated with chill & rigor, night sweating,
diurnal variation, cough, weight loss.

23. Salient feature
On examination , he is ill looking, Conscious,
Oriented, Complete opthalmoplegia on right
eye, 3rd
, 4th
& partial 6th
nerve palsy on left eye.
Fundoscopy & other systemic examination is
normal. There is no sign of meningeal
irritation.

24. Provisional diagnosis
• Diabetes Mellitus Type 2
• Basal meningitis

25. Differential diagnosis
• Myaesthenia gravis
• ICSOL involving brain stem
• Mononeuritis cranial multiplex
• Cavernous sinus thrombosis

26. Investigations
CBC:
Hb % - 13.2
WBC -7000 cu/mm
Neu-45 %
Lymph- 47 %
Mono -5.9 %
Eosino- 1.1%
Platelet- 195000
ESR- 82mm in 1st
hour

27. S. Electrolytes
Na-136 mmol/l
K-4.5 mmol/l
Cl: 106 mmol/l
HCO3: 25 mmol/l
Ca- 9.2 mmol/l
Mg- 0.8 mmol/l
Phosphate-3.8

28. Lipid profile:
TG: 166 mg/dl
T. Chol : 144 mg/dl
LDL: 85 mg/dl
HDL: 40 mg/dl
LFT:
ALT: 28 iu/L
AST: 36 iu/L
RFT:
S. Creatinine: 0.8mmol/l
S Urea: 31 mmol/l
HbA1c: 6.2%

29. Sugar - Nil
Albumin – Nil
Ketone- Nil
Epi. cell: A few /HPF
Pus cell: 1-2 /HPF
RBC: Nil
URINE R/M/E

30. Chest X-Ray
NORMAL

31. ECG
Normal

32. MRI of Brain

33. MRI of Brain

34. MRI of Brain

35. MRI of Brain

36. MRI of Brain

37. MRI of Brain

39. Special investigations
ANA: Negative
P-ANCA: Negative
C-ANCA: Negative
VDRL: non- reactive
TPHA: non- reactive
CRP: 46 mg/l
MT: 6mm

40. CSF study
• Appearance: clear
• Protein: 136g/L
• Sugar: 3.2mmol/L( Corresponding blood
glucose-12mmol/l)
• Cell count: Total WBC 350 cells/cmm
• Lymphocytes: 99%
• Total RBC: 25cells/cmm
• Bacterial antigen: Negative

41. Final diagnosis:
• Diabetes mellitus type 2
• Tubercular meningitis

42. Treatment:
Short acting insulin
Anti TB drugs
Tab. pyridoxine
Tab. Prednisolone
Supportive treatment
Patient was counseled about Course and
prognosis of the disease

43. Follow UP
Patient was advised to follow up in Neurology
after 2 weeks for further clinical evaluation &
management

44. Video clip
• Oculoparesis is improved along with ptosis

45. Acknowledgement :
Department of Ophthalmology