Case 28 - 28 M with Quadreparesis

 A 28 year old male came with chief complaints of sudden fall followed by weakness of both the lower limbs (paraplegia) and loss of hand grip 10 days back, associated with bowel and bladder incontinence.


History of present illness:
Patient was apparently asymptomatic 1 month back, following which he developed productive cough, low grade fever for which he underwent sputum studies and tested positive for AFB bacilli and started ATT - HRZE regimen, 2 tab according to weight/PO/OD.

He developed generalized weakness and myalgia 15 days back.

10 days back, patient got up from bed and went to open the door and suddenly fell down, with no loss of consciousness and no froathing. Following which his brother got him up and since then Patient developed bowel and bladder incontinence.
No sensory impairment.

Past history:
He is a known case of TB since 1month and on ATT - HRZE
Not a known case of DM,HTN, ASTHMA, EPILEPSY, THYROID DISORDERS, STROKE, CAD.

Personal history:
Diet - mixed
Appetite - normal
Sleep - Adequate
Bowel and bladder incontinence + since 1 week
No allergies 
No addictions

Family history:
His father is a known case of TB and used ATT for 2 years

General examination:
Patient is conscious, coherent, co-operative and oriented to time, place and person

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema.

Temperature - afebrile
PR - 80 BPM
RR - 16 cpm
BP - 100/70 mm Hg

Systemic examination:
CNS:


1.     HIGHER MENTAL FUNCTIONS:

a.   Consciousness – intact 

b.   Well Oriented to time, place and person 

c.   Speech and language –  normal

d.   Memory – immediate-retention and recall, recent and remote - intact

a.     No Delusions, hallucinations

b.     No Emotional lability 

c.     MMSE score - no cognitive impairment 


Cranial nerves - intact

  

Motor :


                  Right.        Left
Tone. UL.  N.              N
           LL  increased. Increased
Power UL.  4/5.         4/5
             LL.  1/5.          1/5
Cranial.nerves.  : Intact
Sensory system : normal
Reflexes:
            Right.         Left
Biceps. 3+.             3+
Triceps. 3+.            3+
Supinator. 2+.         2+
Knee.          3+.         3+
Ankle.        3+.          3+

Plantar: extensor

TEST

RIGHT

LEFT

I – SPINOTHALAMIC

1.     Crude touch

2.     Pain

3.     Temperature

II – POSTERIOR COLUMN

1.     Fine touch

2.     Vibration

3.     Position sense

4.     Romberg’s sign

III – CORTICAL

1.     Two point discrimination

2.     Tactile localisation

3.     Graphaesthesia

4.     Stereognosis

 

Normal

Normal

Normal

 

Normal

Normal

Normal

      -

 

Normal

Normal

Normal

Normal

 

Normal

Normal

Normal

 

Normal

Normal

Normal

      -

 

Normal

Normal

Normal

Normal


CVS:
S1, S2 heard
No thrills
No Murmurs

Respiratory system:
Trachea - central
BAE +
NVBS heard
No added 







Per abdomen:
Soft, non tender
Bowel sounds - heard
Hernial orifices - normal
No palpable masses

Provisional diagnosis:
Cervical myelopathy?
Potts spine?

Investigations:







Treatment given:
1. Inj. Optineuron 1Amp in 100ml NS  IV/OD
2. Inj. Thiamine 200mg in 100ml NS IV/TID
3. ATT - according to body weight 2 tab PO/OD
4. Bp/ PR/ Spo2/ Temp charting

Update:

FINAL DIAGNOSIS:   Quadreparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 level.

   UPDATE: 
He had surgical drainage of abcess at Osmania and getting discharged tomorrow

Outcome of intervention : 
Patient regained control over bowel and bladder, 
Improvement in power and tone..( as he is walking now) 
Adviced to continue ATT.       

                                                   


Discharge summary:

Disharge Date: 24 - 06 - 21

Treating faculty:
Dr. Rakesh Biswas (HOD)
Dr. Arjun (Asst Prof)
Dr. Divya (PGY2)
Dr. Usha (PGY2)
Dr. Sai Charan (PGY1)
Dr. Pallavi (Intern)
Dr. Kusuma (Intern)
Dr. Sameera (Intern)
Dr. Siddharth (Intern)
Dr. CVS Siddharth (Intern)

Diagnosis: 
Quadreparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 level.

Chief complaints:
A 28 year old male came with chief complaints of sudden fall followed by weakness of both the lower limbs (paraplegia) 10 days back, associated with bowel and bladder incontinence.

History of present illness:
Patient was apparently asymptomatic 1 month back, following which he developed productive cough, low grade fever for which he underwent sputum studies and tested positive for AFB bacilli and started ATT - HRZE regimen, 2 tab according to weight/PO/OD.

He developed generalized weakness and myalgia 15 days back.

10 days back, patient got up from bed and went to open the door and suddenly fell down, with no loss of consciousness and no froathing. Following which his brother got him up and since then Patient developed bowel and bladder incontinence.
No sensory impairment.

Past history:
He is a known case of TB since 1month and on ATT - HRZE
Not a known case of DM,HTN, ASTHMA, EPILEPSY, THYROID DISORDERS, STROKE, CAD.

Personal history:
Diet - mixed
Appetite - normal
Sleep - Adequate
Bowel and bladder incontinence + since 1 week
No allergies 
No addictions

Family history:
His father is a known case of TB and used ATT for 2 years

General examination:
Patient is conscious, coherent, co-operative and oriented to time, place and person

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema.

Temperature - afebrile
PR - 80 BPM
RR - 16 cpm
BP - 100/70 mm Hg

Systemic examination:
CNS:
Speech - normal
No signs of meningeal irritation
                  Right. Left
Tone. UL. N. N
           LL increased. Increased
Power UL. 4/5. 4/5
             LL. 1/5. 1/5
Cranial.nerves. : Intact
Sensory system : normal
Reflexes:
            Right. Left
Biceps. 3+. 3+
Triceps. 3+. 3+
Supinator. 2+. 2+
Knee. 3+. 3+
Ankle. 3+. 3+

Plantar: extensor

CVS:
S1, S2 heard
No thrills
No Murmurs

Respiratory system:
Trachea - central
BAE +
NVBS heard
No added 

Treatment given:
Day 1:
1. Inj. Optineuron 1Amp in 100ml NS IV/OD
2. Inj. Thiamine 200mg in 100ml NS IV/TID
3. ATT - according to body weight 2 tab PO/OD
4. Bp/ PR/ Spo2/ Temp charting

Day 2&3:
Same treatment followed.

Day 4:
Inj. Monocef added.

Advice at Discharge:
Referred to Higher center for neurosurgical decompression as MRI showed
1. Infectious spondylitis of C4, C5, C6, C7 and D1 vertebral bodies with significant erosion at C5 - C6 level and the intervening disc space.
2. Epidural abscess at C5 - C6 level measuring 58 x 4 x 18 mm causing cord compression and posterior displacement of the cord.
3. T2/STIR mild cord hyperintensity - suggestive of edema.
4. Prevertebral collection (max AP dimension - 10 mm) extending from C2 to D3 level suggestive of anterior ligamentous spread.

Update : 
Dr. Saicharan Kulkarni:

Update regarding
30M Diagnosed with Cervical Potts spine 

Surgery done : (9/7/21)
C5 Corpectomy with iliac bone graft placement with plate fixation.

Intra operative findings : 
C5 osteomyelitis with granulation tissue noted
C5 body disjunction noted.

Condition at discharge : (14/7/21)
Tone : 
upper limbs normal
Lower limb hypotonia
Power : 
B/L upper limb 4/5
B/L lower limb 2/5

Condition at follow up : (27/7/21)
Power : 
B/L upper limb 4/5
B/L lower limb 3/5
(Patient able to walk with walker.)
Suture removal done

He had surgery on 9th sir then he was shifted to ICU where he didn't even tried to walk or move because of pains at cervical and iliac regions 
After 3 days he was shifted to genral ward where he could move his fingers, limbs and from next day he started walking With walker sir.

Outcomes: 
Improvement in power 3days after surgery(from 0/5 to 2/5) And 3/5 at first follow up(18days)

Control in bowel and bladder from next day after surgery.

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