differential diagnosis

19 years old female reside in Bahri came to casualty c/o lower limb weakness and unsteady gait for 9 years. the condition started about 9 years ago by deterioration of walking notices by her mother which is progressive specially in the last years to the degree that patient is fall down many times and dumped the school, the patient didn't seek any medical advice because of financial and social problems, weakness involves only the lower limbs equally but at the last two years there is a history of tremors mainly kinetic one on both hands now regressive in course now became rather unnoticed, there is no history of trauma and symptoms suggesting an increase in intracranial pressure and no symptoms suggest cranial nerves involvement there is no deterioration in speech or writing abilities noticed by the mother or sphencteric disturbances apart from increase in frequency of micturition on the last year, there systemic review is insignificant apart from delayed development of secondary sexual characteristics and primary amenorrhea, the patient had no history of any chronic illness or chronic cough and no family history of similar condition.

Examination showed a fully conscious patient with intact cranial nerves and average intelligence. a power grade 4+ in both lower limbs with a clasp knife spasticity and pendualr reflexes in both lower and upper limbs. No deformities noticed there is dicoorination in both upper and lower limbs with fine intention tremors and scanning speech negative rebound fenomina and Romberg sign. back examination was normal chest examination showed a signs of upper and middle right lobes fibrosis. liver is 4cm bcm other systems were normal.

Investigatios sowed: normal CBC renal and liver functions and abdominal U/S, CXR confirmed the prescence of right sided fibro consolidation with mediastinal shift, mantoux was +20 blood pcr for tuberculus bacilli and sputum for AFB were negative

Brain MRI showed a signs of moderate brain atrophy and evidences of white matter disease suggesting a metabolic or degenerative disease no SOL seen