CASE SCENARIO 2 - PARA-PARESIS I

CASE 1

COMPLETE CASE REF - https://vaish7.blogspot.com/2020/05/medicine.html?m=1

23 y/o male auto-driver came with a complaint of B/L Lower Limb Weakness since 5 DAYS ; ALSO A SUDDEN FALL WHEN HE ASCENDED TO URINATE along with Tingling and numbness in the lower extremities . He gives history of Vomiting non-projectile and non bilious.

5 months ago, was diagnosed with a PSOAS ABSCESS which was drained. 10 days back, A scrotal abscess was drained.

He has had a history of multiple sexual partners. 

Priority Complaint - 

• Weakness in B/L LL since 5 days ; difficulty to carry out life tasks.

Analysis - Acute onset Lower Limb weakness - Causes could be problem in

• CNS
• PNS
• Musculoskeletal system 

POSITIVE FINDINGS ON CLINICAL EXAMINATION - 

• Hypotonia of Both Lower Limbs
• Power of Rt and Lt LL is 2/5 and 0/5 resp.
• Plantar reflex is Extensor
• Right Sided Deep Tendon reflexes are more reactive with Rt Knee and Ankle Jerk scoring 3+ and Ankle Clonus present on Rt side.

Analysis - 

• Hypotonia could mean [A] LMN Lesion [B] Initial Stages of UMN Lesion
• Decreased LL power score according to MRC SCALE of                                                                    2/5 on Rt meaning - active movement present when gravity is eliminated                           0/5 on Lt meaning - No contraction
• Extensor Plantar reflex - Babinski's sign positive - UMN lesion 
• 3+ score in deep tendon reflex elicitation indicates VERY BRISK RESPONSE, MAY/MAY NOT BE NORMAL AND POSITIVE ANKLE CLONUS in Rt LL with normal response of 2+ in Lt LL indicating a probability of UMN Lesion

CAUSES -

• In case of UMN lesion - BRAIN, SPINAL CORD
• In case of LMN lesion - SPINAL CORD , PERIPHERAL NERVES , NEUROMUSCULAR JUNCTION, MUSCLE 

         - Tingling and numbness maybe Peripheral Neuropathy

         -  Autoimmune NMJ disoders, seen in HIV patients due to immunodeficiency.

            [LEMS - Lambert Eaton Myasthenic Syndrome]

         - Muscular Pathology 

• Vascular - Ruled out as there is no h/o Intermittent Claudication Pain/Edema of LL with Skin Changes. 
• Trauma - No h/o Trauma
• Anemia - No pallor, ruled out.

ATTEMPT TO LOCALIZE WITH KNOWN HISTORY AND CLINICAL FINDINGS - 

• 23 M, acute onset B/L LL weakness, h/o multiple sexual partners, past h/o psoas abscess shows B/L LL hypotonia, muscar weakness, + Babinski's sign, probable hyper-reflexia and ankle clonus on Rt side. Upper Limbs are normal.
• The above signifies findings in support Initial stages UMN Lesion and some LMN Lesion signs in lower limb with Normal upper limbs
• HENCE, THE LESION COULD BE BETWEEN T3 - L3 or BETWEEN L4 - S2.

FEW DIFFERENTIAL DIAGNOSIS -

• POTT'S DISEASE / TUBERCULOSIS SPONDYLITIS - 

- Mode of infection is mostly, Hematogenous spread of Mycobacterium tuberculosis from an extraspinal site like lungs.

- Infection reaching adjacent ligaments and soft tissues may be lead to formation of COLD ABSCESS. SPREAD OF INFECTION FROM LUMBAR VERTEBRAE TO PSOAS MUSCLE, FORMING A COLD ABSCESS. Patient has a history of psoas abscess 5 months ago.

- Neurological symptoms in Pott's diesease can occur at anytime and present with PARESIS, ABNORMAL TONE AND REFLEXES.

- In some cases bacteria invades the Dura and can lead to Meningitis/Tuberculoma causing symptoms such as vomiting.

- Since he exhibits high risk behavior, he has to repeatedly be tested for HIV. HIV cannot be detected during window period [6-12 weeks after exposure]. TB is one of the most common Co-Morbidities of HIV.

INVESTIGATIONS - 

1. Complete Blood Picture, ESR and RBS 

2. Liver Function Test

3. Kidney Function Test

4. Serology - HIV, HbsAg, Anti HCV antibodies, VDRL 

5. Culture to isolate the organism causing Psoas Abscess

6. CSF Analysis

7. Mantoux Test

8. NAAT for Rapid Sputum Examination

9. Chest X-ray

10. MRI - Brain and Spinal Cord

TREATMENT - 

1. Treatment Goals - [a] To confirm diagnosis and eradicate the infection

                                  [b] Recover/maintain neurological function

                                  [c] Functional return to everyday tasks

2. Treatment Proper - [a] Anti TB Therapy 

                                   [b] Surgical Spinal Cord Decompression/ Surgical Spinal Fusion/ Spinal                                                     Immobilization, if indicated.

                                   [c] Analgesics

                                   [d] Physio Therapy

3. Indicators of Good Prognosis -  [a] Young Age

                                                       [b] Good General Conditions

                                                       [c] Short duration of neural complications

                                                       [d] Early onset cord involvement with late onset neural symptoms

• MULTIPLE SCLEROSIS - 

- Occurs in 20s, Initial symptom can be weakness in lower extremity with tingling and numbness.

- It is a demyelinating disease with varied etiology.

SPECIFIC INVESTIGATIONS -

1. CSF Analysis

2. MRI Brain and Spine

3. Evoked Potential Test 

4. Blood Tests for ruling out conditions similar to MS 

TREATMENT - 

A. NON PHARMACOLOGICAL - 

     1. Physio Therapy

     2. Dietary Modifications -  Preliminary research regarding dietary interventions helping in                                                               controlling chronic inflammatory disorders. Links of which are below,

 -  http://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Documents/Diet-  and-Multiple-Sclerosis-Bhargava-06-26-15.pdf

 -  https://multiple-sclerosis-research.blogspot.com/2016/05/clinicspeak-intermittent-fasting.html

             [a] Probiotics in diet improve health and reduce disability

             [b] Vitamin D supplementation 

             [c] Fish Oil Supplementation

             [d] Ketogenic Diet 

B. PHARMACOLOGICAL - 

     1. Acute Relapse Management - a. Prednisone                                                                                                                                          b. Plasmapheresis

     2. Disease Modifying Agents -   a. Beta Interferons                                                                                                                                  b. Natalizumab                                                                                                                                        c. Fingolimod

                                                      d. Glatiramer acetate

                                                     e. Mitoxantrone

• SPONDYLODISCITIS - 

- Rare but serious disorder in which there is a primary infection of the inter-vertebral disc with secondary infections of the vertebrae, starting at the end plates. Mostly associated with E.coli / M.tuberculosis. In this case, there is a strong evidence of TB.

INVESTIGATIONS SAME AS FOR POTT'S DISEASE EXCEPT HERE, GADOLINIUM ENHANCED MRI IS PREFERRED.

TREATMENT - 

A. NON-PHARMACOLOGICAL - Physio Therapy 

B. PHARMACOLOGICAL - 

a. CONSERVATIVE TREATMENT - 

Carried out for 4 - 6 weeks. Indicated only in mild cases/when surgery is too risky. Anti-Tubercular Therapy ; Immobilization of Spine esp. in cases of ventral column/ Lower Lumbar or Lumbo-sacral Involvement for maximum for six weeks after which there are high chances of pseudoarthroses and kyphotic malposition of spine. 

In Children immobilization is not done.

b. SURGERY - 

ATT with radical surgical debridement and stable reconstruction.

• INTRA CRANIAL TUMOUR

• STROKE - B/L Anterior Cerebral Artery Infarction [rare]

INVESTIGATIONS DONE FOR THIS CASE - 

For complete detail, pls refer to the link of the case.  

ABNORMAL FINDINGS ARE 

• ESR ELEVATED - PROBABLY DUE TO INFLAMMATION
• SGOT, SGPT ELEVATED - It could be due to ATT, but was the LFT done after starting patient on drugs ? Other causes could be Myopathy.
• ALKALINE PHOSPHATASE ELEVATED 
• CREATININE SLIGHTLY REDUCED - Lower muscle mass? Diet low in protein ? 
• LYMPHOCYTE COUNT REDUCED - Chronic infection ? Was ATT started before the blood examination ?
• CHEST X-RAY - Coarse reticulonodular densities distributed throughout the parenchyma on both sides, probably Miliary tuberculosis.

X-RAY ABDOMEN - Shows left psoas abscess

• MRI BRAIN - 

           Meningeal enhancement/ exudates with multiple nodules in pulmonary apices suggesting             pulmonary koch's and disseminated TB. Ring enhancing lesion in Rt and Lt Cerebral                 Hemispheres.

             

DIAGNOSIS GIVEN - L4, L5 Infective spondylodiscitis with paraparesis, left psoas abscess and ring enhancing lesions in RT and LT  Cerebral Hemishperes.

TREATMENT - 

1. ANTI TB THERAPY 

2. T.Benadon 40mg/ OD

3. T.Pregabalin 75mg/po/h/s

4. OINT. MEGAHEAL AND SITZ BATH WITH BETADINE TID

5. FREQUENT CHANGE OF POSITION

Questions - 

1.WHAT IS THE REASON FOR 

• Elevated Liver enzymes and reduced Creatinine and Lymphocytes
• Frequent Change of Position recommended to the patient
• Rt sided reflexes being more pronounced than left sided ? Does is have anything to do with Lt sided enhancement being more than Rt side in the MRI as pyramidal tracts cross-over at lower medulla ?

2. WHEN HE FELL, DID HE JUST FALL BECAUSE HIS LEGS WERE WEAK / HE LOST HIS BALANCE / HE BECAME UNCONSCIOUS ?

SUGGESTION -

• Electromyography to rule out muscle problems in case of no reason to justify elevated liver enzymes.
• Repetation of HIV testing for 12 weeks - 6 months to rule out false negative status due to widow period.

SOURCES

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117730/
• https://www.physio-pedia.com/Pott%27s_Disease
• https://physio-pedia.com/Spondylodiscitis
• https://physio-pedia.com/MS_Multiple_Sclerosis
• https://geekymedics.com/lower-limb-neurological-examination/
• https://www.ncbi.nlm.nih.gov/books/NBK396/
• https://medatrio.com/upper-motor-neuron-lower-motor-neuron-lesions

 ANSWERS TO THE QUESTIONS POSED BY THE FACULTY - 

1. ANATOMICAL STRUCTURES CAUSING PARA-PARESIS 

Ans - Insult in Brain, Spinal cord at the level of L4, L5 verterbrae

2. MOST LIKELY ETIOLOGY AND PATHOLOGY IN THE ANATOMICAL LOCATION

Ans-  Spread of TB from lungs to vertebrae mostly via blood. Once spread, it may infect vertebrae, inter-vertebral discs, epidural or intra-dural space within the spinal canal or adjacent tissues. Infection may go upwards or downwards, destroying the anterior and posterior longitudnal ligaments and periosteum from the front and sides of the vertebral bodies. Cold abscess [PSOAS ABSCESS] can form if the infection reaches the adjacent ligaments and soft tissues.

Neurological symptoms can occur at any point of time.

In this case, L4, L5 are infected and probably the inter-vertebral disc between both of them leading to para-paresis of both lower limbs. Infection ascended to brain also, as seen in MRI

3. THERAPEUTIC OPTIONS 

Ans- As mentioned above near Pott's Disease and Spondylodiscitis.