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.