THE CULPRIT -TUBERCULOSIS

An another case of PARAPARESIS

Presented by Alekhya , 8th semester

I have been gives clinical case data to solve in an attempt to understand the concept of paraperesis.

You can find the entire patient's clinical case data in link here:https://vaish7.blogspot.com/2020/05/medicine.html?m=1

 

Following is my analysis of the case 

MAIN COMPLAINTS OF THE PATIENT ARE:

1.Weakness of bilateral lower limbs since 5days

2.Tingling and numbness

3.sudden fall

4.vomitings 5 days back 

Explanation of above symptoms

1.Weakness of bilateral lower limbs since 5 days

It can be due to a number of causes,but as the patient gives history of sudden fall it  indicates STROKE which may be causing weakness of lower limbs.

Also his chest x ray is suggestive of "TUBERCULOSIS".

The mycobacterium tuberculosis might have spread by hematogenous route to vertebrae causing POTT'S DISEASE.

Which is evident in the x ray between L4 and L5.

✓The Potts disease causes vertebral damage and intervertebral disc infection leading to cord compression and neurological insults,paraparesis.

✓Paraspinal spread of infection to psoas muscle is common leading to psoas abscess.

* patient is having left psoas abscess, which can cause nerve entrapment.

✓But the patient has bilateral lowerlimb weakness ,so psoas abscess as an etiology can be ruled out.

✓The Potts disease is located at L4 and L5 which compress the CAUDA EQUINA and presents as Potts paraplegia with features:

• Deep tendon reflexes -brisk
• Increased tone
• Extensor plantar response 
• Ankle clonus positive

 " 95% of lesions around cauda equina and conus medullaris cause spinchter involvement early and UMN and LMN mixed paraparesis"(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3691413/).

The patient has hypotonia which is suggestive of LMN lesion and brisk knee and ankle reflex,extensor plantar response ,ankle clonus suggestive of UMN lesion, mixed UMN and LMN PARAPARESIS.

 The tuberculosis has disseminated to brain and meninges which is evident in the MRI SCAN of brain.

"About a quarter of young adults with TBM have acute ischemic stroke which may lead to poor clinical outcome."

(https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-019-4004-5)

•The acute ischemic stroke could be reason for his sudden fall,numbness and tingling .

•As he has lesions in brain causing raised  intracranial tension causing Vomitings.

•The patient had been previously operated for gluteal abscess and scrotal abscess. •Which states the person has weakened immune system.

•The patient is an autodriver with history of multiple sexual partners ,so he is at risk of having HIV .

•As the patient is positive for tuberculosis he is more prone to have HIV.

ANATOMICAL LOCATION OF CAUSE

•L4 and L5 vertebrae (spondylodiscitis)

•cerebral cortex and meninges(tuberculousmeningitis and ring enhancing lesion).

PHYSIOLOGICAL FUNCTIONAL DISABILITY

• Bilateral lower limb weakness
• Tingling and numbness

PATHOLOGY REFLECTING THE CAUSE

• L4,L5 infective spondylodiscitis ,compressing cauda equina.
• Ring enhancing lesions in cerebral cortex and tuberculous meningitis.

INVESTIGATIONS

• Sputum microscopy and CBNAAT for confirming Mycobacterium tuberculosis
• CT angiography and MRI to identify the location of stroke.
• Culture of abcess fluid from psoas abcess to identify the organism.
• HIV testing

TREATMENT 

• Anti tuberculosis therapy
• Incision and drainage of left psoas abscess and antibiotics.