CASE of a 23 yr old male patient with bilateral lower limb weakness

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis and to develop competency in reading and comprehending clinical data including history clinical findings,Investigations&come up with a diagnosis and treatment plan

My analysis of the patient is as follows ••

Chris complaints of patient are :

- Bilateral lower limb weakness associated with tingling & numbness since 5 days

- there is a history of sudden fall

- H/O vomiting- non progectile,non bilious

1 . BILATERAL LOWER LIMB  WEAKNESS

Possible point s to be taken in an account while ruling out paraplegia : -

• onset whether acute/sub acute/ chronic,as it helps to rule out etiology & further easy diagnosis

• h/o back ache&girdle pain

• h/o wasting of muscle s, fasciculation s,tone, pattern of weakness,deep tendon reflexes,plantar response should be ruled out to know whether paraplegia due to UMN /LMN lesions

•h/o fever,cough, expectoration

• h/o involuntary movements

• h/o seizure s,syncope,altered sensorium,loss of consciousness

• h/o bladder/ bowel involvement,raised ICT

Probable causes for weakness :

. Trauma - no history of trauma

.iinfections like - tuberculosis (Potts disease)or viral as it ruled out,no history such infections

. Cerebellar disorders - is ruled out, there is no features like

Ataxia ,nystag nys , seizure s,incoordination,swaying while walking, inability to sit upright

. Metabolic - vitamin B12 defeciency as there is no pallor it is ruled out

Conditions to be ruled by investigation s are :

Spinal cord injury -it suggestive if there is sensory loss ,spinal tract cross

Findings (pyramidal  on one side and contralateral on spinothalamic) ,root plus long tract

Signs (spondylosis ,sarcoidosis) ,urinary retention , numbness

. Tumors - like meningioma ,lymphoma,glioma ruled out on MARI brain scans.. lumbar puncture, Icp monitoring  ,CSF  analysi

. Transverse myelitis -- weakness of limbs, sensory alterations, bowel & bladder dysfunction ruled out , investigation of CSF analysis reveals CSF pleocytosis ,if G index & gadalonium enhancement

 Other demylenating disorders should be ruled out

2 . Vomiting

Possible causes

. Brain tumors -raised ICT eventually to vomiting

. Infections may be due to drug toxicity

PAST HISTORY :

 H/O of sexual exposure

. Operated for gluteal abscess 5 months back & scrotal abscess since 20 days

GENERAL EXAMINATION :

Patient is conscious, coherent,co operative

Vitals with in normal limits, afebrile,no pallor, cyanosis,cclubbing,icterus,koilonychia,lymph adenopathy

. CVS -s1 ,S2 heated no added sounds

. Respiratory - bilateral air entry, normal bronchi vescicuve breath sounds

HIGHER MENTAL FUNCTION s

.. speech,memory, normal

. CNS - intact

MOTOR SYSTEM

                       Right.                Left

Bulk  :          Normal.                Normal

Tone :

         UL         normal.              Normal

         LL.        Hypotonia .        Hypotonia

Power

         UL.        5/5 .                         5/5

         LL.         2/5.                          0/5

 Reflexes

Superfecial reflexes

                      Right.                   Left

  Corneal.      P.                          P

Conjunctiva .  P .                       P

Abdominal.      P.                        P

Plantar.            Extensor.        Extensor

Deep tendon reflexes

                          Right.                   Left

Biceps.            2+.                          1+

Triceps.          2+ .                          1+

Supinator.     3+ .                           2+

Knee.               3+.                            2+

Ankle.              3+.                             2+

Jaw jerk .         1+.                             1+

Clonus.            Present.               Absent

Primitive reflexes - absent

Involuntary movements - absent

Sensory system - normal

MENINGIAL SIGNS

. Neck stiffness - negative

. Kernings sign - negative

. Brudzinkis sign - negative

INVESTIGATIONS

Hiv  - negative

It is found that ,there is significant enhancement which represents MENINGIAL enhancement or exudates or multiple nodules in pulmonary apices, are suggestive of pulmonary Koch's and disseminate distribute tuberculosis

..so the patient is now found to have TB, but didn't have any clinical findings of TB. He should be evaluated for Potts disease of spine

TREATMENT :

 T.ATT 3tabs/day FDC

T. Bernadine 40 mg/ of

T. Pregabalin 75mg/po/h/s

Oint.. megaheal for local application

Sitz bath with betadineTID

Frequent change of possitive

DIAGNOSIS for this case is :

LUMBAR infective spondylodicitis & spondylitis due toTB (Potts disease of spine to be ruled out)

Recommended investigation :MARI to rule out TB of spine

Possible anatomical location involved may be : - vertebrae,disc of spinal column

.. physiological functional disability

- bilateral lower limb weakness

Pathology in this case may be due to :

Any injury to spinal column due to infections may cause the bones around the spinal cord causing damage to nerves i.e leading to limb weakness

• As investigation showed pulmonary foci& disseminate d TB it can be cause for bilateral weakness

    Pathology in it is .. primary focus may be active) quisent in lungs/ mediastinal nodes leading to simultaneous involvement of paradisal part of vertebrae through arterial spread. Infectious foci which then erodes the cartilage plate&destroy the disc.granulomatous & infective material may be compressed b/w body, ligamentous structures ,pushed along the tissue planes & laterally in to spinal column.. finally lead to TB spondylitis

. BIOCHEMICAL abnormalities :

Total protein CSF pattern, albumin,total cholesterol, reactive protein levels

• TREATMENT :

Family is screen ed for TB,& tubercular therapy given