CASE REPORT 1:
A 23 yr old, previously well male,who was a autorickshaw driver by profession, came to the hospital with complaints of :
- Weakness of both the lower limbs since 5 days
- Complaint of tingling and numbness
- History of vomitings 5 days back, 3-4 episodes, nonprojectile ,non bilious but with food particles.
- History of a fall ,unable to getup on his own and received help from his father
- Gluteal abscess since 5months (operated 5 months back)
- Scrotal abscess since 20 days(incision and drainage 10 days back)
Prior to this he had no similar complaint but has history of contact with multiple sexual partners.
EXAMINATION:
On examination, a drained Gluteal abscess was found (appeared as ulcer)
SENSORY SYSTEM : Normal
MOTOR SYSTEM :
Hypotonia of Both Lower Limbs
Power of Rt and Lt LL is 2/5 and 0/5 resp.
Plantar reflex is Extensor
Right Sided Deep Tendon reflexes are more reactive with Rt Knee and Ankle Jerk scoring 3+ and Ankle Clonus present on Rt side
MENINGIAL SIGNS: Negative
INVESTIGATIONS :
Hemogram, Serology for HIV,HCV and HBSAg , LFT , RFT , CXR , X-RAY ABDOMEN, MRI BRAIN,ESR,RBS .
CBP: Normal
SEROLOGY: Negative
LFT AND RFT:
Low creatinine
High SGOT
High Alkaline phosphotase
ESR 45 mm/1st hr
RBS 99 mg/dl
X ray images:
MRI images of the above patient are as below
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QUESTIONS
1.WHAT IS THE LIKELY DIAGNOSIS AND WHAT ARE THE DIFFERENTIALS?
A.Paraparesis with L4,L5infective spondylodiscitis
" Spondylodiscitis can be defined as a primary infection (accompanied by destruction) of the intervertebral disc (discitis), with secondary infections of the vertebrae (spondylitis), starting at the endplates. It can lead to osteomyelitis of the spinal column. "
[ 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)]
DIFFERENTIALS:
1. Pott's disease or Tuberculosis of spine
2. Transverse myelitis secondary to viral infections like HIV, HTLV-1 or Brucellosis etc.
Further investigations needed to rule out these differentials:
CT-guided biopsy for TB
2ME, IFA, ELISA for Brucellosis
Serology, antigen detection, PCR for HTLV1
2.WHAT IS THE LIKELY PATHOGENESIS OF THIS CONDITION?
A. HYPOTONIA: The defect may lie at the
1.Central nervous system: Central hypotonia with defects at the brain or spinal cord (umn or lmn).
TESTS TO RULE OUT OTHER DISEASES OR TO MEASURE MUSCLE INVOLVEMENT:
- Peripheral nerves (motor and/or sensory) : Peripheral hypotonia that may affect any place between the spinal cord and muscle. ✓Neuromuscular junction at the connection between the nerve endings and the muscles may be affected. ✓The nerves bring in the impulse from the central nervous system that makes the muscle maintain contraction or a resting muscle tone. Defects may lie at the level of the muscles.
Further investigations needed:
EMG/NCV: Used to diagnose disorders of lower motor neurons, as well as disorders of muscles and peripheral nerves. Nerve conduction studies help to differentiate lower motor neuron diseases from peripheral neuropathy and can detect abnormalities in sensory nerves.
MRI: Images can help diagnose brain and spinal cord tumors, eye disease, inflammation, infection, and vascular irregularities that may lead to stroke.
SPONDYLODISCITIS:
Pathogenesis:
" In the beginning of pyogenic spondylodiscitis the anterior aspect of the vertebral end plate will abrade. Also loss of disc height, gradual development of osteolysis and further destruction of the subchondral plate will manage. Later on there will be more destruction of the vertebral body, new bone formation and kyphotic deformity. Because of the erosion of the vertebral end plates, the vertebra can collapse.
Tuberculous spondylodiscitis is also identified by the loss of the anterior subchondral part of the vertebral body.
The difference between the two types, is that the intervertebral disc and the joint space are preserved longer in the tuberculous spondylodiscitis. "
3.WHAT ARE THE THERAPEUTIC OPTIONS IN THAT SITUATIONS?
A.
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.
RECENT ADVANCES:
" Current standards in the setting of SD are continuously evolving, as can be seen in the recent advances in the field of radiological diagnostics, and the use of growth factors and cell-therapy strategies to promote infection eradication and bone healing after surgery. "
QUERIES:
✓WHAT IS THE REASON FOR ELEVATION OF HIS LIVER ENZYME LEVELS?
✓IS THE COLD ABSCESS RESPONSIBLE FOR THE SPONDYLODISCITIS?
✓WHY DID'NT THE PATIENT SHOW ANY SYMPTOMS OF TUBERCULOUS?
References:
