CASE 3
COMPLETE CASE REF -
18 y/o M with CC of difficulty in walking since 1 month, was insidious on onset and gradually progressing reaching a point where he finds difficulty in climbing stairs, in holding chappals, standing after sitting ; he complains of PAIN in calf muscles with positive CALF TENDERNESS; there is h/o FEVER and WASTING of muscles ; h/o slipping off of chappals w/o knowledge ; h/o alcohol consumption twice every week.
NEGATIVE HISTORY - NO H/O SIMILAR DIFFICULTY IN UPPER LIMBS OR CRANIAL NERVE INVOLVEMENT ; NO H/O AUTONOMIC NERVOUS SYSTEM ISSUES
ANALYSIS : PATHOLOGY COULD BE -
18 y/o anemic pt with muscle pain, weakness, wasting. With mute plantar reflex and absent deep tendon reflexes in both B/L UL and LL with h/o slipping off of footwear w/o knowledge and h/o fever.
It is an LMN Lesion which could be inflammatory along with peripheral neuropathy.
Points to be kept in mind for arriving at a differential diagnosis -
DIFFERENTIAL DIAGNOSIS WITH SPECIFIC INVESTIGATIONS :
Etilogy is varied. Investigations required are as follows -
- GRBS, THYROID PROFILE, LFT, RFT to rule out endocrine, liver/ renal causes
- PERIPHERAL SMEAR to look for evidence of subacute combined degeneration of Spinal Cord
- Vitamins B12, B1, B6 , E deficiency ; Pyridoxine excess
- Alcohol induced
- Ruling out infectious causes ; ESR
- INFLAMMATORY CAUSES LIKE
- Could be Paraneoplastic
- Hereditary causes - Charc0t-Marie-Tooth-Disease/Familial Amyloidosis - NCS, Nerve Biopsy, Genetic Testing
- Limb Girdle muscular dystrophy
- Myopathies due to enzyme deficiencies
-Infections causing myopathies
- Systemic conditions like Sarcoidosis, etc
Most Myopathies can be detected by-
EMG, NCS, CREAITINE KINASE LEVELS IN SERUM, MUSCLE BIOPSY AND GENETIC TESTING
INVESTIGATIONS DONE ON THE PATIENT
-Normal creatinine levels rule out anyform of active myopathy.
[Though Hypohyroid Myopathy can occur in some cases, but CK levels would be elevated in such cases]
- Common Peroneal Neuropathy is seen in Pts who are thin built/ sit cross-legged quite often/ wear tight-fitting foot-wear/Charcot-Marie-Tooth Disease/Polyarteristis Nodosa
DIAGNOSIS GIVEN TO THE PATIENT
Paraparesis secondary with B/L Common Peroneal and Sural Neuropathy with Scabies.
TREATMENT
NEGATIVE HISTORY - NO H/O SIMILAR DIFFICULTY IN UPPER LIMBS OR CRANIAL NERVE INVOLVEMENT ; NO H/O AUTONOMIC NERVOUS SYSTEM ISSUES
ANALYSIS : PATHOLOGY COULD BE -
- VASCULAR
- MUSCULOSKELETAL
- IN CNS
- IN PNS
- Moderate built and poor nourishment
- Pallor - present
- Bulk of the muscles in B/L UL and LL is decreased - suggesting wasting
- Hypotonia in B/L LL with normal UL
- Decreased Power in B/L LL with normal UL
- Plantar Reflex is MUTE
- Deep Tendon Reflexes are absent B/L in both UL and LL
- Positive Calf Tenderness
18 y/o anemic pt with muscle pain, weakness, wasting. With mute plantar reflex and absent deep tendon reflexes in both B/L UL and LL with h/o slipping off of footwear w/o knowledge and h/o fever.
It is an LMN Lesion which could be inflammatory along with peripheral neuropathy.
Points to be kept in mind for arriving at a differential diagnosis -
- Age of onset
- Acute onset, pain, weakness with h/o fever
- Weakness is symmetrical and gradually progressing in LL
- Mental functions are intact
- No h/o intermittent claudication pain / edema in LL with skin changes, ruling out vascular pathology
- No h/o Diurnal Variation/relief on exertion of the weakness ruling out major NMJ disorders
- Pain could be due to compression of nerves/ pathology in muscle
DIFFERENTIAL DIAGNOSIS WITH SPECIFIC INVESTIGATIONS :
- Polyneuropathy
Etilogy is varied. Investigations required are as follows -
- GRBS, THYROID PROFILE, LFT, RFT to rule out endocrine, liver/ renal causes
- PERIPHERAL SMEAR to look for evidence of subacute combined degeneration of Spinal Cord
- Vitamins B12, B1, B6 , E deficiency ; Pyridoxine excess
- Alcohol induced
- Ruling out infectious causes ; ESR
- INFLAMMATORY CAUSES LIKE
- Gullian Barre - LUMBAR PUNCTURE, ELECTROMYOGRAPHY [EMG] , NERVE CONDUCTION STUDY [NCD]
- Chronic Inflammatory Demyelinating Poyneuropathy - EMG, NSD, Sural Nerve Biopsy, USG of Peripheral Nerves
- VASCULITIS DUE TO SLE/Sjogren's/Rheumatoid Arthritis/ Polyarteritis Nodosa - ESR, Anti-Nuclear Antibodies, Rheumatoid Factor, anti-CCP Antibodies
- Could be Paraneoplastic
- Hereditary causes - Charc0t-Marie-Tooth-Disease/Familial Amyloidosis - NCS, Nerve Biopsy, Genetic Testing
- Radiculopathy due to intervertebral disc herniation in Lumbar region
-Spinal stenosis can be caused due to varied etiology
-INVESTIGATIONS : 1. MRI and X-ray 2. CT myelogram
- Physical test for confirmation of sciatica is Straight leg raise to produce Lazarević's sign.
- Myopathies
- Limb Girdle muscular dystrophy
- Myopathies due to enzyme deficiencies
-Infections causing myopathies
- Systemic conditions like Sarcoidosis, etc
Most Myopathies can be detected by-
EMG, NCS, CREAITINE KINASE LEVELS IN SERUM, MUSCLE BIOPSY AND GENETIC TESTING
INVESTIGATIONS DONE ON THE PATIENT
- Serology - All negative
- Chest X -ray - Normal
- Creatinine Kinase Levels - Normal
- T3 - Decreased
- NCS - Shows B/L common peroneal and sural axonal neuropathy.
- Sural Nerve Biopsy was planned
- Later pt was found to have Scabies also.
-Normal creatinine levels rule out anyform of active myopathy.
[Though Hypohyroid Myopathy can occur in some cases, but CK levels would be elevated in such cases]
- Common Peroneal Neuropathy is seen in Pts who are thin built/ sit cross-legged quite often/ wear tight-fitting foot-wear/Charcot-Marie-Tooth Disease/Polyarteristis Nodosa
DIAGNOSIS GIVEN TO THE PATIENT
Paraparesis secondary with B/L Common Peroneal and Sural Neuropathy with Scabies.
TREATMENT
- Tab PARACETAMOL 650 mg TID
- Injection NEOMOL 100ml i.v. infusion if Temp increases >101 F
- PERMETHRIN 5% LOTION overnight, to be applied on entire body except face
- Tab B COMPLEX OD
No comments:
Post a Comment