E log CASE 3
23 OLD MALE WITH COMPLAINTS OF LOWER LIMB WEAKNESS
And further causing infarcts in pyramidal tracts thereby resulting in Paraparesis.
Hello everyone ,I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
After going through the patient details as given by our Intern Mam through the following link..
https://vaish7.blogspot.com/2020/05/medicine.html?m=1
My analysis of the patient is as follows :
CHIEF COMPLAINTS :-
▪️weakness of bilateral lower limbs and complaints of tingling and numbness.
▪️vomitings 5days back 3-4 episodes non projectile non bilious food particles is content.
▪️when he got up for urination,suddenly he had a fall and got up with the help
▪️gluteal abscess since 5months ( operated 5 months back
▪️scrotal abscess since 20 days (incision and drainage 10 days back).These two abscess are cold abcess
NO Similar complaints in the past.
NO other relevant past history.
NO other relevant past history.
Paraparesis:
Partial paralysis of lower limbs
It can be due to trauma, vitamin B12 deficiency, neuromuscular disease, and any peripheral vascular disease.
But here, with the symptoms, tingling & numbness it can be concluded as a neuronal problem.
ON EXAMINATION:
Vitals and General examination - normal
CNS examination:
conscious
speech - normal
cranial nerves- intact
Motor system:
Vitals and General examination - normal
CNS examination:
conscious
speech - normal
cranial nerves- intact
Motor system:
bulk- normal
tone- hypotonia in both lower limbs power- decreased power in both lower limbs
Reflexes - present
tone- hypotonia in both lower limbs power- decreased power in both lower limbs
Reflexes - present
plantar reflex- extensor in both right and left
Ankle clonus- present in rt, absent in left
Involuntary movements- absent
Sensory system- normal
Cerebellar signs- absent
Meningeal signs- absent
Involuntary movements- absent
Sensory system- normal
Cerebellar signs- absent
Meningeal signs- absent
HIV : non reactive
X-ray and MRI :
There is a significant enhancement that represents meningeal exudates. The following lesions in MRI suggest disseminated tuberculosis.
1.ANATOMICAL LOCATION OF THE PROBLEM
FROM THE above investigations and reports, the anatomical location of present paraparesis problem lies in the anterior right and left cerebral hemispheres, midline of falx cerebri and pyramidal tracts
Bilateral hypotonia suggestive of LMN lesions
- Hyperreflexia of knee and ankle reflex suggestive of UMN lesions
- Ankle clonus suggestive of UMN lesion)
2.Etiology of PARAPARESIS
The possible etiology might be due to the spread of Mycobacterium Tuberculosis
x-ray chest showed multiple nodules in pulmonary apices suggestive of Pulmonary Tuberculosis and a possible Miliary tuberculosis ( disseminated TB)
As the MRI suggests of disseminated tuberculosis and ring enhancing lesions in the brain.The possible etiology might be spread of this mycobacterium from lumbosacral abcess to the blood vessels and from the blood vessels it reaches the circle of Willis in brain and further into anterior communicating artery occlusion And further causing infarcts in pyramidal tracts causing Paraparesis.
3.POSSIBLE INVESTIGATIONS
As we are suspecting mycobacterium from MRI investigations we need to further confirm the organism
Best step is to isolate the organism
▪️sputum microscopy
▪️monteaux test
▪️cbnaat
▪️Bronchoscopy followed by bronchoalveolar lavage study
▪️Culture of abcess fluid Hence from the above investigations we can be able to confirm which type of mycobacterium it is and further treatment option is done.
Further investigations :
▪️On x-ray of abdomen-L4 L5 spondylodiscitis with left psoas abscess ( which are seen in pott’s disease) which might have been a reason for cord compression and paraparesis
https://images.app.goo.gl/GY9GAcQX8vZk6D1k9
Just an example showing spndylodiscitis
4-Provisional Diagnosis from the case.
Paraparesis with L4,L5infective spondylodiscitis with left psoas abscess with ring enhancing lesions in right and left cerebral hemispheres with healing ulcer in right gluteal region secondary to drained gluteal abscess with pyocele left side operated ( 10 days back)
5- Therapeutic modality
1)T.ATT 3 tabs/day fdc
2)T.Benadon 40mg/od
3)T.pregabalin 75mg/po/h/s
4)OINT.MEGAHEAL FOR LOCAL APPLICATION
5)FREQUENT CHANGE OF POSITION.
References :
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