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Case 349
Matheus Hideki Taborda1, Matheus Kahakura Franco Pedro2,3,4, Bernardo Corrêa de Almeida Teixeira1,5,6
1Postgraduate Program, Federal University of Paraná, Rua General Carneiro 181, Curitiba, PR, Brazil 80060-900.
Radiology
|April 28, 2026
Summary
A 76-year-old man with neurological symptoms including double vision and dizziness was diagnosed with a rare inflammatory brainstem encephalitis. This condition, characterized by specific MRI findings and cerebrospinal fluid abnormalities, requires prompt diagnosis and management.
Area of Science:
- Neurology
- Neuroimmunology
- Neuroradiology
Background:
- A 76-year-old male presented with a month of worsening binocular diplopia and a week of progressive dysarthria and dizziness.
- Patient history included hypertension, dyslipidemia, hypothyroidism, and chronic cervicobrachialgia.
- Neurological examination revealed left abducens nerve palsy, right lower facial palsy, horizontal nystagmus, and right lower limb paresis.
Purpose of the Study:
- To investigate the cause of the patient's progressive neurological deficits.
- To identify potential inflammatory or infectious etiologies.
- To characterize the neuroimaging and cerebrospinal fluid findings.
Main Methods:
- Brain Magnetic Resonance Imaging (MRI) was performed.
- Laboratory blood tests were conducted, including extensive serologic testing for autoimmune markers.
- Cerebrospinal fluid (CSF) analysis included opening pressure, cell count, glucose, total protein, and oligoclonal bands.
Main Results:
- Brain MRI demonstrated abnormalities in the brainstem.
- C-reactive protein was elevated (135 mg/L), while autoimmune serology was negative.
- CSF analysis revealed elevated total protein (750 mg/L) and positive oligoclonal bands, with normal cell count and glucose.
Conclusions:
- The clinical presentation, MRI findings, and CSF profile are suggestive of an inflammatory brainstem encephalitis.
- Despite negative autoimmune markers, the findings warrant consideration of inflammatory demyelinating diseases.
- Further investigation and management should focus on this rare neurological condition.
