PARAPARESIS

I've been given this case data to solve in an attempt to understand and analyize the topic "PARAPARESIS" based on patient clinical data in order to develop competency in reading and comprehending clinical data related to Paraparesis and come up with a suitable diagnosis.

You can find the original case in the link below-

FOLLOWING IS THE PROBLEM LIST ACCORDING TO PATIENT'S PRIORITY:

MAIN COMPLAINTS:
  1. Weakness of both lower limbs
  2. Vomitings
  3. Gluteal abscess
  4. Scrotal abscess
EACH COMPLAINT IN DETAIL:

    1. WEAKNESS OF BOTH LOWER LIMBS:
  • ONSET:Sudden
  • Since 5 days
  • ASSOCIATED SYMPTOMS:Tingling and Numbness
  • PAST HISTORY:had a fall when he got up for urination and was picked up by his father
  • PROBABLE DIAGNOSIS:
    • Peripheral Neuropathy
    • INFECTIVE SPONDYLODISCITIS(spine infections-Most commonly-Tuberculosis)
    • Gullian-Barre Syndrome/Multiple Sclerosis
    • Sciatica
    • Myasthenia Gravis
    • Spinal lesion or tumor/Toxins
  • INVETIGATIONS RECOMMENDED:
    • X-Ray Spine
    • CT SCAN and MRI
    • Radionucleotide Imaging
    • Blood culture,if due to some infection
  • TREATMENT TAKEN:
    • PHARMACOLOGICAL:
      • Tab. Benadon-40mg/od =supplement of vitamin B6 given for proper functioning of the nerves
      • Tab. Pregabalin-75mg/po/h/s =to treat pain due to nerve damage
    • NON-PHARMACOLOGICAL:None
  • TREATMENT RECOMMENDED:
    • Antitubercular therapy(if TB is suspected)
    • Treatment of the infection
    • Rest
    • Physiotherapy
     2. VOMITINGS:
  • ONSET and DURATION: 5 days back
  • PAST HISTORY: 
    • 3-4 episodes
    • Non-projectile and Non-bilious
    • CONTENT: Food Particles
  • PROBABLE CAUSES:
    • Infections
    • Medication-induced vomiting
    • Ingestion of toxins
    • Emotional stress
    • Tuberculoma
    • Spinal tumors
  • TREATMENT:treat the underlying cause/infection
     3. GLUTEAL ABSCESS:
  • Since 5 months
  • PROBABLE DIAGNOSIS:
    • Injection site abscess
    • TB of LUMBAR VERTEBRAE
    • Psoas abscess
    • Salmonella infection
    • Amoebic gluteal abscess
    • Crohns disease
    • Carcinoma of colon
  • TREATMENT GIVEN:
    • NON-PHARMACOLOGICAL:
      • Incision and drainage (operated 5 months back)
      • Frequent position change recommended
    • PHARMACOLOGICAL:
      • Ointment Megaheal for local application
      • Sitz Bath with BETADINE TID
     4. SCROTAL ABSCESS:
  • Since 20 days
  • PROBABLE CAUSES:
    • Bacterial Epididymitis secondary to tuberculous infection (most common)
    • Testicular abscess that ruptures through tunica albuginea
    • Drainage of appendicitis into scrotum through a patent processus vaginalis.
  • TREATMENT:
    • Incision and Drainage (done 10 days back)

PAST HISTORY:
  • No similar complaints in past 
  • H/o multiple sexual partners
  • Auto driver by profession( high risk behaviour)
  • Not a known case of HTN/DM/ASTHMA/CAD
GENERAL EXAMINATION:
  • The patient was conscious,coherent and cooperative
  • Pallor,Icterus-absent
  • No cyanosis,clubbing,lymphadenopathy,Edema
  • VITALS-Normal
  • All systems found to be normal
  • CNS--Conscious with cranial nerves intact and speech-normal
ON EXAMINATION:
  • MOTOR SYSTEM:
    • Normal Bulk of muscles
    • Lower Limb muscles showed  BILATERAL HYPOTONIA
    • Lower Power of lower limb muscles
  • SUPERFICIAL REFLEXES and DEEP TENDON REFLEXES:Present and Normal
  • Absent PRIMITIVE REFLEXES
  • Absent INVOLUNTARY MOVEMENTS
  • SENSORY SYSTEM:Normal
  • No Cerebellar or Meningeal Signs
INVESTIGATIONS SHOWED:
  • Elevated ESR (45mm/1st hr) ----->indicates INFECTION
  • X-Ray Shows:
      
 
--Multiple nodules in pulmonary apices suggest of pulmonary kochs and disseminated tuberculosis.
 
  • MRI Shows:

RING ENHANCING LESION

Significant enhancement which represents meningeal enhancement or exudates and following lesions in MRI

DIAGNOSIS:
  • Paraparesis with L4 , L5 INFECTIVE SPONDYLODISCITIS
  • Left PSOAS ABSCESS
  • Ring enhancing lesions in the cerebral hemispheres on MRI suggestive of PYOGENIC BRAIN ABSCESS---> maybe TUBERCULOMA
  • with HEALING ULCER in RIGHT GLUTEAL REGION secondary to drained gluteal abscess 
  • with LEFT SIDED PYOCELE (operated 10 days back)

  • ANATOMICAL LOCATION OF THE ROOT CAUSE:
    • Pulmonary tuberculosis disseminating to the vertebral bodies and adjacent Intervertebral discs
RECENT ADVANCES:
The patient has been  diagnosed with definite TB Infection which has disseminated to the spine and also caused the gluteal and scrotal abscess and also the pyogenic brain abscess(tuberculoma) and thus,has been started on Antitubercular therapy.

REFERENCES:

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