A CASE OF PARAPARESIS

A 18 year old male with "difficulty in walking since one month"

I've been given this case to understand the concept of  paraperesis .You can find the entire patient case history in the link below

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

As per the clinical data provided there is:

•Difficulty in walking since 1 month

•Bilateral symmetrical pain and weakness of   lower limbs which was insidious in onset and gradually progressive

•Difficulty in standing from sitting position

•Wasting and thinning of lower limb muscles

• Pain and tenderness in calf muscles.

Following is my analysis of this patient's problem.

The cause could be Neuropathy or Myopathy.

NEUROPATHY

 There is decreased power, hypotonia,loss of bulk and weakness of limb muscles,areflexia suggesting a lower motor neuron lesion.

1.ANTERIOR HORN CELL

 

✓Spinal muscle atrophy (type 3) ?

     It is a genetic condition due to defect in SMN 1 gene;which codes for SMN protein crucial for survival of motor neurons.

Signs and symptoms:

 -areflexia

 -muscle weakness and hypotonia

 -difficulty in standing,climbing stairs.

Diagnosis : genetic testing and electromyography.

"https://en.m.wikipedia.org/wiki/Spinal_muscular_atrophy"

2.NERVE ROOT

✓Acute lumbar disc prolapse (although rare in adolescents) compressing the nerve roots.

• Due to trauma,lifting heavy objects,jumping from heights.

Signs and symptoms : lower back pain, unilateral or bialteral sciatica

*As our patient doesn't complain of them,it can be ruled out.

3.PERIPHERAL NERVES

Peripheral neuropathy can be caused by trauma,systemic illness like diabetes,autoimmne conditions and alcohol.

The patient is alcoholic and poorly nourished ,so he might have B1,B6,B12,Folate deficiency leading to alcoholic neuropathy?

Signs and symptoms :

With a peripheral nerve injury, you may experience symptoms that range from mild to seriously limiting your daily activities. Your symptoms often depend on which nerve fibers are affected:

• Motor nerves. These nerves regulate all the muscles under your conscious control, such as walking, talking, and holding objects. Damage to these nerves is typically associated with muscle weakness, painful cramps and uncontrollable muscle twitching.
• Sensory nerves. Because these nerves relay information about touch, temperature and pain, you may experience a variety of symptoms. These include numbness or tingling in your hands or feet. You may have trouble sensing pain or changes in temperature, walking, keeping your balance with your eyes closed or fastening buttons.
• Autonomic nerves.  excessive sweating, changes in blood pressure, the inability to tolerate heat and gastrointestinal symptoms.

'https://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/syc-20352061'

The patient has only " motor symptoms"

There is no tingling,numbness,sensory deficit,urinary incontinence.(pure motor involvement)

Diagnosis:EMG, nerve conduction studies(NCS),nerve biopsy.

Based on nerve conduction studies:

Bilateral common peroneal and sural axonal neuropathy.

Other investigations

•Creatine kinase :92 IU/L within the normal range so myopathic conditions can be ruled out.

•peripheral blood smear:normocytic and normochromic , no B12 deficiency

•serology: negative for HIV,HBV,HBC , no viral etiology present.

ANATOMIC LOCATION OF LESION

Neurogenic : based on nerve conduction studies ,lesion is in the peripheral nerves.

It is a axonal polyneuropathy as there is involvement of peripheral nerves  in roughly the same areas on both sides of the body.

PHYSIOLOGICAL FUNCTIONAL DISABILITY

✓ inability to walk

✓ difficulty in standing from sitting position

✓difficulty in climbing stairs.

PATHOLOGY reflecting root cause

Wallerian degeneration and reduction in myelination of nerve fibres in peripheral neuropathy.

Normal pathology of a peripheral nerve

Alcohol consumption can have direct toxic effects on the nerve and incresed oxidative stress due to ethanol and nutritional deficiency.

Others Conditions :

•Fever 

•Scabies

TREATMENT 

✓Non pharmacological:strength training ,exercises to improve the range of movements,diet rich in vitamins like fruits and vegetables for proper nerve function and preventing damage.

✓pharmacological:

 -Pain medications:NSAIDS ,antiepileptics ,antidepressants to treat neuropathic pain

 -paracetamol for fever

 - permethrin for scabies

 -Transcutaneous electric nerve stimulation

Stem-cell therapy is also being looked at as a possible means to repair peripheral nerve damage, however efficacy has not yet been demonstrated.

"https://en.m.wikipedia.org/wiki/Peripheral_neuropathy"