Paraparesis case study -1

                                      Case of a 23 year old male with paraparesis 

                                          Submitted by : Simran Dash

                                          MBBS - IV  | Roll number - 153

"I've been given this case data here:

https://vaish7.blogspot.com/2020/05/medicine.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: 23 years

Chief complaints of the patient:

Ø  Weakness in both lower limbs (Paraparesis)

Ø  Gluteal abscess

Analysis:

I) Paraparesis:

ØOnset - Sudden

ØDuration - 5 days

ØProgression - Gradually progressive

Ø  Associated complaints - Vomiting 5 days back (non-bilious and non-projectile)

Ø  Tingling and numbness.

Ø  There is no diurnal variation (rules out myasthenia gravis)

II) Gluteal abscess:

Ø  Onset - Sudden

Ø  Duration - 5 months

Ø  Was operated

Also has a history of scrotal abscess 20 days back for which Incision and drainage was done 10 days back.

Past History:

Ø  Has a history of multiple sexual partners.

Ø  Did not get vaccinated recently (Influenza vaccine can cause GBS like syndrome)

From the history I am of the opinion that it could be a motor neuron disease.

On examination:   

Ø  Hypotonia in both the Lower limbs.

Ø  Power is also reduced in both the lower limbs. (RL - 2/5; LL - 0/5)

Ø  Babinski’s sign is positive.

Ø  Deep Tendon Reflexes are reduced.

Ø  Sensory system - normal

Investigations done on this patient are:

Ø  CBP: normal

Ø  CUE: normal

Ø  MRI OF Brain: There is significant enhancement which represents meningeal enhancement or exudates

Ø  Chest x ray: multiple nodules in pulmonary apices 

Ø  Serology for HIV, Hepatitis B: negative

 

So, from the above I am of the opinion that:

Anatomical location of the root cause could be in the Spinal cord because:

Ø  Sudden in onset.

Ø  More common.

 Findings which are needed to confirm this can be:

Ø  Bowel and bladder movements because urinary incontinence can point towards a lesion in the spinal cord.

Ø  Mass reflex should be tested. If mass reflex is present that indicates severe spinal cord disease.

Pathological cause for this problem could be:

Ø  Vascular

Ø  Compression

Ø  Demyelination

Microbiological cause:

Ø  Mycobacterium tuberculosis

Ø  HIV (because he has multiple sexual partners)

Ø  Treponema pallidum

Biochemical cause:

Ø  Defect in the gene “chromosome 9 open reading frame 72,” or C9ORF72 (seen in ALS)

Possible differential diagnoses could be:

Acute Transverse myelitis

ALS (Amyotrophic Lateral Sclerosis)

Post vaccinial (ruled out from history already)

Arachnoiditis:

·     TB spine (because Elevated Alkaline phosphatase points towards a problem in the bone, psoas abscess, Intracranial space occupying lesions and meningeal enhancement in MRI, and multiple modules in pulmonary Apices)

·      Tabes Dorsalis (neurosyphilis)

Thrombosis of anterior spinal artery (myelomalacia)

Ø  Lathyrism (can be ruled out from family history)

 ØSubacute combined degeneration of Spinal cord

Ø  Alcoholic liver disease (because there is elevated SGOT, and sensations of tingling and numbness)

Additional investigations required are:

Ø  Mantoux test: positive in TB

Ø  Lymph node biopsy

Ø  Lumbar puncture and CSF Analysis (for features of Froin’s loculation syndrome)

Ø  Serum vitamin B12 levels

Ø  Electromyography (muscles will be affected in motor neuron disease)

Ø  Nerve conduction study (to differentiate between motor neuron disease and peripheral neuropathy)

Ø  VDRL test for syphilis

Ø  Pupillary reflexes to be tested (Argyll Robertson pupil in Tabes dorsalis)

Ø  Gait should be tested (tabetic gait characteristic of tabes dorsalis)

Ø  Genetic testing for ALS

Treatment received by him:

Ø  ATT 3 tabs/day fdc

Ø  T.Benadon 40mg/od

Ø  T.pregabalin 75mg/po/h/s

Ø  Oint.megaheal for local application

Ø  Sitz bath with betadine tid (For the gluteal abscess)

ØFrequent change of position

Additional treatments required are:

 In caries spine:

·         Application of traction in early stage.

·         Later on, “plastic jacket” is applied for immobilization.

Ø  Physiotherapy:

·         Passive movements are carried out in the lower limbs once or twice daily.

·         Later on, arrangement of wheel chair, walking calipers are done according to the necessity.

Ø  Surgery:

·         Drainage of cold abscess

·         Laminectomy for caries spine.

REFERENCES:

• https://pubmed.ncbi.nlm.nih.gov/31232571/
• https://en.wikipedia.org/wiki/Pott_disease
• https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Motor-Neuron-Diseases-Fact-Sheet
• https://www.medscape.com/answers/1169231-113721/what-is-tabes-dorsalis
• Clinical methods of medicine by Arup kumar Kundu
• Hutchison’s clinical methods
• Davisdson's principles and practive of Medicine
• Harrison's principles of internal medicine