TUBERCULOSIS PRESENTING AS PARAPARESIS

P.NIKHITHA
ROLL NO.130

I HAVE 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.



FOLLOWING IS MY ANALYSIS OF THIS PATIENT'S PROBLEM:
THE PROBLEMS IN ORDER OF PRIORITY I FOUND ARE:
  1. weakness of bilateral lower limbs since 5 days and complains of tingling and numbness.
  2. vomiting 5 days back,3-4 episodes, non projectile,non bilious food particals is content.
  3. when he got up for urination, suddenly he had a fall and got up with the help of father.
PAST HISTORY
  • gluteal abcess since 5 months(oprated 5 months back)
  • scrotal abcess since 20 days(incision and drainage 10 days back)
  • H/o multiple sexual partner
  • autodriver(high risk behaviour)
AND THE REASON FOR THE PROBLEM 1 IS;
By hearing complaints of weakness, tingling sensation and numbness , it id clear that the problem may lie in muscle , nerve or NMJ pathology.and by following analysis we will come to know the anatomical location ,etiology and pathogenesis 

GENERAL EXAMINATION:
  • pallor, icterus absent
  • no cyanosis, clubbing, lymphadenopathy, edema
  • afebrile
  • vitals -normal.
  • cns-intact
  • speech-normal
  • cranial nerves -intact
MOTOR SYSTEM EXAMINAION;
ABNORMAL FINDINGS ARE;
  • TONE AND POWER-
  1. hypotonia in both lower limbs
  2. reduced power in both lower limbs(right-2/5, left-0/5)
  • SUPERFICIAL REFLEXES-
  1. corneal,conjuctival,abdominal reflexes are found to be normal.
  2. extensor plantar reflex is presnt in both LL (which indicates positive babinski sign) @ this can mean that he may have an underlying nervous system or brain condition thats causing his reflexes to react abnormally.
  • DEEP TENDON REFLEXES-
  1. biceps, triceps, supinator,, knee, ankle, jaw jerk are found to be less reactive to stimulus.
  2. Ankle clonus is found in right LL. (D/D- interuption of UMN fibres such as stroke, multiple schlerosis OR metabloc alterations such as hepatic failure or serotonin syndrome)
  3. Involuntary movemets-absent.
SENSORY SYSTEM EXAMINATION: Normal
CEREBELLUM:  No titubation ,nystagmus ,intentional tremors, pendular knee jerk, and co-ordination test -normal.
MENIGNGEAL SIGNS: No neck stiffness, negative kernigns sign and Brudzinkis sign.

By the end of examination, it is analysed that, 
the affected part could be nervous system
 and brain excluding brainstem

INVESTIGATIONS:
ABNORMAL LEVELS OF-  
  • Low creatinine
  • high SGOT
  • high ALK. ph
On performing x-ray and CT:

 There is significant enhancement which represents meningeal enhancement or exudates and following lesions in mri with multiple nodules in pulmonary apices  suggest of pulmonary kochs and disseminated tuberculosis.

And vomitings are probably due to brain pathogy.


DIAGNOSIS: paraparesis with S 1,2 infective spondylodiscitis with left psoas abcess with ring enhancing lesions in right and left cerebral hemispheres with healing ulcer in right gluteal region secondary to drained gluteal abcess with pyocele left side operated9 10 days back).


Anatomical location for the cause of paraparesis?
  • UMN lesion suggestng features here are:
  1. paresis of movement
  2. diffuse distribution
  3. extensor plantar response.
  • LMN lesion suggesting features here are:
  1. Hypotonia
  2. hyporeflexia
  3. no associated involuntary movements.
  • S 1,2 cord segment affected.
JUSTIFICATION;  muscles paralysed are:
Gluteus ,calf, anterior tibial, peroneal, small muscles of foot.
Reflexes:
* knee jerk present(3+ in right and 2= in left)
*ankle clonus - present
*extensor plantar reflex.

pathology and etiology?
pathogenesis of gluteal and scrotal abcess:
Phagocytosis of tubercle bacilli by RES( monocytes,macrophages)
⇩
Tuberculous granulomas(langhans gaint cells)
⇩
small patches of central caseous necrosis
⇩
coalesce into a large yellow mass 
⇩
breakdown of center to form cold abcess.

  • Tuberculous granulation tissue+ caseous matter = necrotic necrotic bone
  • accumulation beneath the anterior longitudinal ligament.
  • graviate along the fascial planes 
  • present eternally at some distance from the site of original lesion.

pathogenesis of TB spine:
  • bacilli from primary focus through blood stream reach disc space.
  • the deformed spinal column comresses spinal cord producing functional impairment.

Etiology :
follwing are the risks which increased the susceptibility to infection in this patient:
  • works as autodriver(high risk factor)
  • young age
  • low socio-economic status( attributes to malnutrition)
  • alcohoal cosumption.
  • multiple sex partners
Therapeutic options?
Current treatment plan:

  • T.ATT 3 tabs/day fdc
  • T.Benadon 40mg/od
  • T.pregabalin 75mg/po/h/s
  • OINT.MEGAHEAL FOR LOCAL APPLICATION
  • SITZ BATH WITH BETADINE TID
  • FREQUENT CHANGE OF POSITION
suggestions:
  • Anti-TB treatment with the standard drug regimen to be initiated (isoniazid 300 mg daily, rifampicin 600 mg daily, pyrazinamide 2 g daily, and ethambutol 1 g daily). After 3 months of anti-TB therapy, brain MRI and abdominal CT imaging  should be done to see the result.
  • surgery in this case is indicated when:(a) Large leision with rapid deterioration of neurologiccal status OR (b) paradoxical increase in size of lesion following antituberculous therpy. but no significant benifits have been acheived with surgeryinaddition to chemotherapy.
QUERIES!
  1. Why does patient have no symptoms of TB?
  2. Is it LMN or UMN type of lesion? (as patient have both the types of features)
  3. why are SGOT and alk.ph high in this case?


My thoughts on this case
  • There is higher risk of HIV co-infection present among males suffeing from tuberculosis. so,serological test's should be done as soon as possible. http://medind.nic.in/ibr/t00/i1/ibrt00i1p21.pdf
  • fluid from the abcess must have sent to microbiology lab and  should be treated withspecific antibiotic therapy.
  • The issue of drug resistance has to be taken into account, and definitive anti-mycobacterial regimen should be based on susceptibility tests.
  • Lateral radiograph of spine is required.

REFERENCES
THANK YOU!



Popular Posts