Download Neuro Diagnostic Dilemmas: Dissection of a Case (1 hour

Neuro Diagnostic Dilemmas: Dissection of a Case (1 hour interactive lecture format)
Kelly A. Malloy, OD and Erin M. Draper, OD
Kelly A. Malloy and Erin M. Draper have no financial interests to disclose.
● The content of this COPE Accredited CE activity was prepared independently by Kelly A. Malloy and Erin M. Draper
without input from members of the optometric community.
● Kelly A. Malloy and Erin M. Draper have no direct financial or proprietary interest in any companies, products or
services mentioned in this presentation.
● The content and format of this course is presented without commercial bias and does not claim superiority of any
commercial product or service.
ABSTRACT: This interactive lecture revolves around one patient, who presents with asymmetric optic neuropathy.
Join us as we determine the necessary work-up to rule out causes of non-glaucomatous optic neuropathy. With this
interactive format, help us analyze the results of this testing and determine the appropriate management plan for our
patient.
Couse Objectives:
1.
2.
3.
4.
5.
6.
7.
8.
To recognize the importance of providing comprehensive patient care
To recognize when additional testing is warranted based on the clinical exam findings.
To understand how the differential diagnosis for optic neuropathy includes systemic etiologies
To understand how to interpret the results of lab testing and imaging studies.
To appropriately refer patients to other medical specialties outside of eye care.
To better understand the causes for an abnormal SPEP.
To understand the possible causes of lytic lesions of the calvarium.
To understand multiple myeloma.
OUTLINE
1.
Pertinent Exam Findings
a. Optic Neuropathy
i. Causes
1. Glaucomatous
2. Non-Glaucomatous
a. Compression
b. Inflammation
c. Infection
d. Nutritional/Toxic
b.
Optociliary Shunt Vessels
i. Causes
1. Congenital
2. End-stage glaucoma
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3.
4.
5.
Retinal Vein Occlusion
Papilledema
Meningioma
a. Optic Nerve Sheath
b. Sphenoid Wing
2.
Necessary Work-Up
a. Lab Testing
i. Inflammation
1. CBC with differential
2. ESR
3. C-reactive protein
ii. Auto-immune
1. ANA
iii. Inflammatory
1. ACE
iv. Infectious
1. Lyme titer
2. RPR
3. FTA-ABS
v. Nutritional
1. Vitamin B 12
2. Folate
3. Homocysteine
4. Methylmalonic Acid
vi. Other
1. SPEP (serum protein electrophoresis)
vii. Kidney Function
1. BUN
2. Creatinine
3. GFR
b. Imaging
i. MRI brain
ii. MRI orbits
iii. Carotid ultrasound
3.
Interpreting the Results
a. Abnormal Lab Results
i. Elevated homocysteine
ii. Elevated creatinine
iii. Low GFR
iv. Abnormal SPEP
1. M-spike in gamma globulin region, IgG kappa monoclonal band, Elevated
Immunoglobulin G, Reduced Immunoglobulin M
2. Discussion
a. Serum contains a variety of different proteins that will be separated by
electrophoresis into five or six fractions
b. Monoclonal proteins (M proteins) are identical and have the same
electrical charge. On electrophoresis a monoclonal protein will migrate
as a narrow spike which most often appears in the gamma zone.
c. Production of a single, monoclonal protein (M-protein) is a characteristic
feature of multiple myeloma.
d. Monoclonal gammopathies
i. multiple myeloma and spectrum of disease
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ii. plasma cell leukemia
iii. Waldenstrom’s macroglobulemia
iv. AL amyloidosis
b.
4.
5.
MRI Results
i. Small vessel ischemic disease
ii. Azygous ectatic anterior cerebral artery with dominant A1 segment which contacts and
possibly compresses the right optic nerve
iii. Enhancing 1.7 cm lytic lesion in the right frontal calvarium
1. Discussion of lytic lesions
a. Destruction of bone
b. Causes:
i. Primary bone cancers
1. Osteosarcoma
2. Ewing’s sarcoma
ii. Multiple Myeloma
iii. Metastasis to bone
Additional Work-Up
a. Skeletal Survey vs Bone Scan
i. Skeletal Survey
1. Series of X-rays performed systemically to cover the entire skeleton or the
anatomic regions for clinical indications
2. Identifies focal and diffuse abnormalities of the skeleton
3. Indications:
a. Abuse
b. Skeletal dysplasias
c. Infections
d. Metastatic bone disease
e. Multiple myeloma
f. Metabolic bone disease
ii. Bone Scan
1. Procedure that uses small amounts of radioactive material
2. To view the metabolic activity of bones
3. Indications
a. Malignancy
b. Osteomyelitis
c. Occult Fractures
iii. Results
1. Skeletal survey completed
a. No lytic lesions or fractures identified
Referral
a. Hematology / Oncology
i. Concern for multiple myeloma
1. About Multiple Myeloma
a. Part of a spectrum of diseases ranging from monoclonal gammopathy of
unknown significance (MGUS)
b.
Multiple myeloma is a cancer of plasma cells that produce monoclonal
immunoglobulin and invade and destroy adjacent bone tissue.
c.
Systemic effects of multiple myeloma
i. Hyperviscosity
ii. Inhibition of normal immune response; recurrent infections
iii. Interfere with RBC production: leukopenia, anemia and
thrombocytopenia
iv. Increased bone destruction resulting in hypercalcemia, bone
pain and fractures (lytic bone lesions)
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v. Cast nephropathy caused by excess light chains (Bence Jones
protein)
vi. Infiltration of cranial nerves
vii. Infiltration of the leptomeninges of the cerebrum, brain stem,
optic chiasm, pituitary gland, cranial bone marrow, and
subarachnoid blood vessels
ii. Order bone marrow biopsy
1. About bone marrow biopsy
a. Determine percentage of plasma cells in bone marrow
b. Look for plasma cell tumor
iii. Order PET scan
1. About PET scan
a.
Nuclear medicine procedure that uses a small amount of radioactive
substance to evaluate the metabolism of a particular organ or tissue
b.
Indications
i.
ii.
iii.
iv.
Cancer
Neurodegenerative disease
Epilepsy
Trauma
iv. Treatment Options and Prognosis
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