1. Initial Presentation
A 63-year-old lady presented to the Emergency Department (ED) with a one-day history of binocular diplopia and evidence of abducens nerve palsy on examination. Medical history included dyslipidaemia, non-alcoholic fatty liver disease (NASH) and colonic poly removal. Visual symptoms occurred gradually over weeks without diurnal variation. Fundal examination was unremarkable. Admission bloods, chest x-ray and CT brain did not reveal a cause for the patient’s neurological symptoms. Full blood count showed a haemoglobin (Hb) of 10.6 g/dL but was otherwise unremarkable. Her vasculitic, viral, and lyme serology screen were negative. Incidentally, her serum protein electrophoresis showed an IgM paraproteinemia, with a paraprotein level of 4.2 g/L. Renal function, serum calcium, beta-2-micorglobulin and plasma viscosity levels were within normal ranges. An MRI Brain, orbits and cervical cord revealed significant cervical spondylosis with multi-level nerve root impingement. Lumbar puncture (LP) showed raised cerebrospinal fluid (CSF) protein (0.97 g/dL) and leukocyte count (31 x 109/L, 90% lymphocytes, 10% polymorphs). She was discharged with an incidental diagnosis of monoclonal gammopathy of undetermined significance (MGUS) with close follow from neurology and general medicine.