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A rare case of spastic paraplegia

A rare case of spastic paraplegia. Dr. QURBAN HUSSAIN PGR M-II JHL. Anum 20yr/F married house wife resident of Daska Presented in M/E with c/o On and off mild fever 1 month Bilateral lower limb weakness 15-20days

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A rare case of spastic paraplegia

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  1. A rare case of spastic paraplegia Dr. QURBAN HUSSAIN PGR M-II JHL

  2. Anum 20yr/F married house wife resident of Daska • Presented in M/E with c/o • On and off mild fever 1 month • Bilateral lower limb weakness 15-20days • ASOC 1 day

  3. My pt was in her usual state around 1 months back when she developed mild intermittent fever,usually at night associated with sweating and mild occasional cough with yellowish sputum,relieved with medication(pnadol).No significant other associated symptoms. Around 20 days back she developed weakness of Rt.leg and was gradual in onset but progressive and involved Lt.leg after few days pt become unable to walk or stand. weakness was not associated with loss of conciousenessinitailly,no tingling sensation or numbness of any limb,without any loss of bowel or bladder functions. 1 day before presenting to hospital she suddenly become unconcious.

  4. Unconciousness was associated with -mild fever,head and neck pain H/o -occasional cough e sputum -Bilateral blurring of vision -burning micturation NO h/o - loss of sensations in lower limbs -loss of bowel and baldder function -Fits -Rashes on the body,Jointpain,alopecia -Trauma -Previous similar episode -Weight loss or anorexia -Lumps and bumps -Sleep was normal - TB contact - Family H/O similar disease -Hakeem medications

  5. Other system review was normal Past history; medical h/o; 2 miscarriages……first aound 2 months and second around 5 months of pregnancy h/o; on and off fever …1-2 months h/o; treatment for current illness and fever Surgical; H/O.. D&C

  6. Personal History; -married for 1 ½ year -house wife -non smoker ,non addict,nonalchoholic -normal sleep and appetite Gynecological History; -P2A2 -menarche;13 year -3days/30days…regular…normal -No h/o dysmennorhea

  7. SOCIOECONOMIC STATUS; Poor Her husband is labourer Family history; No h/o -Similar disease -DM,HTN,IHD,CVA,TB,Malignancy,

  8. WHAT ELSE YOU WOULD LIKE ASK IN HISTORY?

  9. Differential diagnosis

  10. Differential diagnosis • Spinal cord copression • Anti-phospholipid antibody syndrome • MS • Parasagital meningioma • Anyother SOL involving parasaggital areas of both cerebral hemisperes • SLE • Sagital sinus thrombosis • Myeloproliferative disorders/malignancy

  11. General physical examination A young lady of average height and built,well oriented to time, place and person.with vitals, B.P=100/80 Pulse=86/min,regular Temp=100 F R/R=14/min Pallar+ Jaundie Cyanosis Clubbing Koilonechia Leuconechia JVP Thyroid swelling Sacro-pedal odema Inguinal,axillay and cervical lymph nodes Neck stiffness +

  12. CNS Examination; In emergency her GCS=12/15 Ward GCS=15/15 MOTOR SYSTEM; Lower limb Inspection;muscle bulk was equal on both sides Bilaterally foot drop Tone; was incresed on both sides and it was spastic. Reflexs; ankel and knee jerk were exaggeraed on both sides Plantars; upgoing on both sides Power; bilaterally around 3/5 Upper limb; normal

  13. Bilateral foot drop

  14. Sensory system; All sensations were intact in all 4 limbs Spine exam;normal with no gibbus or any other deformity Respiratory system; unremarkable Cardiovascular system; unremarkable GIT; unremarkable

  15. What else you would like to examine???

  16. Eye examination

  17. EYE EXAMINATION -Visual acuity; rt.6/6 lt.6/18 -Bilateral abduction----absent(6th nerve) -Bilateral upward and downward gaze limited -bilateral papill odema All other cranial nerves were intact.

  18. Briefly • Young female presenting with spastic paraparesis with no spinal levels,bilateral foot drop and bilteral 6th nerve palsy

  19. Differential diagnosis?

  20. Differential diagnosis • Midline brain lesions • MS

  21. What investigations you would to do in this case?

  22. investigations • Complete Blood count with ESR • RFTs and LFTs and S/E,complete urine exam • X-ray chest • MRI spine • CT Brain/MRI Brain with contrast • Lumber punction for CSF • Nerve conduction studies of lower limb • Sputum for AFB • ANA • Anti-phospholipid antibodies • Anti-d DNA antibodies • HIV • USG Abdomen pelvis

  23. Investigations HB=9.9 TLC=6600 PLT=550000 B/UREA=22 CREATININE=0.8 BILIRUBIN=0.7 NA+= 144 K+=4.6 HBSAG= neg ANTI HCVE=neg

  24. Urine exam and culture; 2-3 pus cells/HPF Candidial growth ULTRASOUND Abdomen pelvis; Normal X.RAY CHEST AND ECG; Normal

  25. MRI SPINE………normal

  26. CSF examination; Volume; 06ml Color; colorless Clot formation; absent Glucose; 54 mg/dl (BSR at the time of LP 160 mg/dl) Protein; 338 mg/dl RBcs; nil/cmm Tlc; 08/cmm DLC; polys 50% lymph 50% Gram staining; no micro organism seen Z-n staining; no AFB seen

  27. ANA facter; negative Antiphospholipid antibodies ;normal ESR 60 mm/1st hr HIV; negative

  28. Multiple ring enhancing lesions involoving both cerebral hemispheres with perilesional odema in para falx region with signs of vasculitis. • Finding are suggestive of bilateral multiple tuberculomas

  29. Diagnosis • Bilateral parasagital tuberculomas

  30. management Before the definativediagnosis --treatment of meningoencephalitis was given. Then after definative diagnosis -ATT……12-18 months Isoniazid,rifampicin,pyrazinamide and streptomycin instead of ethambutol because of better penetraion. -Steroids……0.15mg/kg i/v or oral for 6-8 weeks then tapper off to limit neurological deficit and brain odema and inflammation. -Neurosugical opinion……..conservative management. -Phsiotherapy of the pt for lower limbs and mobilization

  31. Bilateral parasaggital SOL and Bilateral foot drop • Foot drop has been known to occur in peripheral ,spinal and muscular dystrophies • But itcan occur even in central lesions especially when lesions is involving the parasagital area near motor strip of leg area. • Cases has been reported with bilateral foot drops with paraplegia having bilateral para sagital meningiomas .

  32. Midline lesions of brain • Parasagital meningioma….more common presents with paraplegia • Metastatic SOL • Tuberculomas • Sagital sinus thrombosis

  33. Parasagital meningiomas • Incidence rate is 25% of all brain tumors. • Usually slow growing • Arise from falx and can extend upward and can involve superior sagital sinus. • Presents commonly -monoparesis of contralateral side initially…can involve the other side after extension -signs of raised intracrainal pressure -fits -may remain even asymptomatic

  34. Treatment is surgical removal of the lesion. • Chemotheray and radiotherapy have poor results. Radiotherapy is mainly used as adjuvant therapy for incompletely resected, high-grade and/or recurrent tumors. It can also be used as primary treatment in some cases of optic nerve meningiomasand some unresectable tumors. • Prognosis is excellent with tumors which are completely resectable. • Can recur…..incomplete resected,malignant and multiple tumors.

  35. Thank you

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