THE PATIENT

This woman was born in Hyderabad, Pakistan in 1937, and had lived in Mumbai, India since 1981. In October 1984 she was found to be anaemic due to menorrhagia, and she had fainted in an elevator, fracturing her left ankle. During her hospital stay, she was given a blood transfusion for her anaemia. No operation was performed. Three months later, she developed jaundice due to hepatitis B infection. In June 1985, she experienced progressive difficulty in walking with aching in her legs. She also complained of involuntary jerking of both lower limbs occasionally during the day, and waking her at night.

NEUROLOGICAL EXAMINATION

When she was first examined by a neurologist in mid 1985, she had a spastic paraparesis. Power was grade 3 in the right lower limb and grade 4 in the left lower limb. Significant spasticity was observed in both lower limbs, more on the right side. The deep tendon reflexes in her lower limbs were exaggerated with extensor plantars.

Apart from a mild subjective reduction in vibration sense at her ankles, sensory examination was normal. Her bladder and bowel functions were preserved. Higher mental function, cranial nerves, and upper limbs were all normal. Apart from the positive HBsAg, all other routine laboratory investigations including blood count, ESR, sugar, VDRL, HIV, and B12 were normal. A brain CT scan …