Paraparesis case study - 3

        Case of a 18 year old male with paraparesis

                     Presented by : Simran Dash

                     MBBS- IV | Roll number : 153

I've been given this case data here:

https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

This may develop my competency in:

a) reading and comprehending clinical data related to "paraparesis"    including history, clinical findings, investigations.

b) come up with a diagnosis such as:

1) Anatomical location of the root cause.

2) Physiological functional disability.

3) Biochemical abnormalities that could be a root cause at a molecular

     level.

4) Pathology that could reflect the root cause at a cellular level

c) a treatment plan for each of these patients of paraparesis that can 

    have a pharmacological and non-pharmacological component.

d) learning the scientific basis of diagnostic and therapeutic approach 

in terms of past collective experiences and experiments (aka  

evidence-based medicine).

Age : 18 years

Chief complaints of this patient are : Paraparesis causing difficulty in walking 

Onset - insidious 

Duration - 1 month 

Progression - gradually progressive

Site - both proximal and distal muscles are involved

No diurnal variation ( rules out myasthenia   Gravis)

Associated complaints -

     i) Pain in the lower limbs since 1 month

    ii) Difficultly in standing from sitting position.

    iii) Difficulty in climbing stairs.

    iv) Difficulty in wearing chappals 

     v) Difficulty in holding objects.

Past history : 

      He drinks alcohol twice in a week since 2 years.

From the history I am of the opinion that it is a case of peripheral neuropathy.

On examination :

       - Pallor is present ( could be Megaloblastic anaemia)

       - He also has fever 

       - Hypotonia of both the lower limbs

       - Muscle bulk is also reduced in both the lower limbs 

       - Babinski sign is negative 

       - Deep tendon Reflexes are absent.

       - Burrows in the web spaces of hands with a positive family history. Not associated with pain. ( could be Norwegian scabies associated with immunodeficiency )

Investigations done in this patient :

1. CBP - normocytic normochromic anemia ( rules out Vitamin B12 deficiency)
2. CUE
3. Serology - negative for HIV, Hepatitis-B, Syphilis.
4. Chest X ray - normal 
5. ECG - normal 
6. Nerve conduction study - to see whether the defect is in myelin sheath or axon. It showed bilateral common peroneal and sural neuropathy.
7. Thyroid profile - ruled out thyroid myopathy.

So from the above I am of the opinion that

Anatomical location of the root cause could be in the axons of the peripheral nerves because:

        - Motor functions are affected.

        - Difficultly in grasping objects

        - Nerve conduction study showed bilateral Sural nerve and common peroneal neuropathy.

        - Ankle jerk reflex is absent .

Pathological cause could be :

        - Toxic : Alcohol

        - Deficiency : Vitamin B12

        - Infective : Leprosy

        - Demyelination : Guillian barre syndrome 

Microbiological cause :

         - Mycobacterium leprae 

         - HIV (but serology is negative for HIV) 

         - Treponema pallidum ( serology is negative)

Differential diagnosis on the basis of this :

1. Leprosy ( because history of difficulty in wearing and holding chappal)
2. Alcoholic neuropathy
3. Vitamin B12 deficiency (because mild anemia is also present ) 
4. Guillain barre syndrome 

              a) Has a history of fever which is suggestive of a viral infection - CMV 

              b) No Sensory abnormalities
              c) involvement of both proximal and distal muscles.

   5.  Thyroid myopathy ( thyroid profile ruled it out)

   6.  Arsenical polyneuropathy 

https://pubmed.ncbi.nlm.nih.gov/15175974/

Additional investigations required are :

1. CSF for albumino- cytological  dissociation ( suggestive of GBS )
2. Slit skin smear for acid fast Mycobacterium leprae ( to rule out leprosy)
3. EMG ( to differentiate neuropathy from myopathy)
4. Estimation of arsenic in hairs, nails and urine - for arsenical polyneuropathy.
5. Serum vitamin B12 Levels
6. Liver function tests ( to confirm Alcoholic neuropathy) 
7. MRI brain
8. Muscle biopsy
9. EDX ( Electrodiagnostic testing) can confirm GBS - “often demonstrates features of demyelination, such as temporal dispersion, significantly slow conduction velocities, and prolonged distal and F-wave latencies.”          

          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152164/

Treatment received by this patient :

1. T.PCM 650mg/ TID
2. INJ.NEOMOL 100ml/ IV INFUSION IF TEMPERATURE >101F
3. TEMPERATURE CHARTING 4th HOURLY AND TEPID SPONGING
4. PERMETHRIN 5% LOTION OVERNIGHT APPLICATION ALL OVER BODY EXCEPT FACE (for scabies)

Additional treatment required:

1. Complete abstinence from alcohol .
2. For painful peripheral neuropathy- PREGABALIN may be helpful
3. INJ. Vitamin B12 - twice weekly I.M. May be helpful for megalobalstic anemia.
4. Physiotherapy can be tried .
5. High dose IVIG therapy (0.4 mg/kg/day for 5 days) for GBS
6. Plasmapheresis- for GBS
7. For leprosy - Multidrug therapy should be given 
8. Arsenic poisoning - Vitamin E and selenium maybe helpful.
9. Vitamin supplements to improve nerve health (folate, thiamine, vitamin- B12, B6)

Non pharmacological treatment modalities:

       

   1.  Physical therapy to help with muscle atrophy.

  2. Orthopaedic appliances to stabilise extremities.

  3. Safety gear, such as stabilising footwear to prevent injuries.

  4. Special stockings for your legs to prevent dizziness.

REFERENCES:

 1) https://pubmed.ncbi.nlm.nih.gov/15175974/

 2)  Clinical methods of medicine by Arup Kumar Kundu

 3)  Hutchison’s clinical methods

4) Harrison’s principles of internal medicine

5) Davidson's principles and practice of medicine

6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3152164/

7) https://www.healthline.com/health/alcoholism/alcoholic-neuropathy#treatment