PARAPARESIS-2

'PARAPARESIS'

AN 18 YEAR OLD WITH DIFFICULTY IN WALKING AND BILATERAL WEAKNESS OF LOWER LIMBS

I've been given this case data to solve in an attempt to understand and analyize the topic "PARAPARESIS" based on patient clinical data in order to develop competency in reading and comprehending clinical data related to Paraparesis and come up with a suitable diagnosis.

You can find the original case in the link below-

https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

FOLLOWING IS THE PROBLEM LIST ACCORDING TO PATIENT'S PRIORITY:

MAIN COMPLAINTS:

    1.Difficulty in walking

    2.Weakness of both lower limbs

    3.Pain in lower limb calf muscles

    4.Fever

EACH COMPLAINT IN DETAIL:

    1.DIFFICULTY IN WALKING:

• Since 1 month
• PROBABLE DIAGNOSIS:
• Orthopaedic problems (skeletal deformities,osteoarthritis) --but there is no history of any fractures and no such  findings on X-Ray. --ruled out

•  Medical conditions
• Heart Failure --no such history
• Arterial disease --here, there is no skin atrophy claudication --so it is ruled out
• Obesity --not in this case
• Neurological
• Nerve related
• Muscle related

    2.WEAKNESS OF LOWER LIMBS:

• since 1 month
• ONSET:Gradual
• Progressive in nature
• Site:. Both legs below the knee i.e near calf 
• PAST HISTORY:initially had felt from getting down from tractor one month ago and then walked with wall support
• PROBABLE DIAGNOSIS:
• Lower motor neuron lesions
• Gullian barre syndrome
• UMN Lesions -- but pain and temperature sensations are intact -- ruled out.
• Peripheral Neuropathy

    3.PAIN IN LOWER LIMB CALF MUSCLES:

• Since 1 month
• Aggravated while walking
• Calf tender positive
• H/O difficulty in standing from sitting position
• H/O difficulty in climbing stairs
• H/O difficulty in holding footwear

       4.FEVER:

• Since one week
• Temperature Charting:

The cause of pain may be due to inflammation of these nerves and fever may be due to this inflammation of nerves.

PAST HISTORY:

• No similar complains in the past and no H/O Trauma
• Not a known case of HTN,Diabetes,EPILEPSY,CVA,CAD

GENERAL EXAMINATION: Normal except that there is mild pallor and presence of fever

MOTOR SYSTEM:

• Decreased bulk and tone of lower limb muscles
• Power of all lower limb muscles is found to be 3/5 -- indicating FLACCID PARALYSIS

CRANIAL NERVES are intact

No Cerebellar or Meningeal signs

Superficial and Deep tendon reflexes--Normal

OTHER PROBLEMS:

SCABIES:

• On examination it came to know that he is having scabies  as the lesions are present in the webspaces and on asking history he told there are same lesions in his group of members and acquired from each other.(contagious)

• There is history of alcohol intake and anemia -- this may have led to deficiency of various vitamins leading to PERIPHERSL NEUROPATHY.

• According to the link--

          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370340/

• The information goes as follows--

                 "Chronic alcohol consumption produces painful peripheral neuropathy for which there is no reliable successful therapy, mainly due to lack of understanding of its pathobiology.

Alcoholic neuropathy involves coasting caused by damage to nerves that results from long term excessive drinking of alcohol and is characterized by spontaneous burning pain, hyperalgesia and allodynia.

The mechanism behind alcoholic neuropathy is not well understood, but several explanations have been proposed.

These include activation of spinal cord microglia after chronic alcohol consumption, oxidative stress leading to free radical damage to nerves, activation of mGlu5 receptors in the spinal cord and activation of the sympathoadrenal and hypothalamo-pituitary-adrenal (HPA) axis. Nutritional deficiency (especially thiamine deficiency) and/or the direct toxic effect of alcohol or both have also been implicated in alcohol-induced neuropathic pain.

Treatment is directed towards halting further damage to the peripheral nerves and restoring their normal functioning. This can be achieved by alcohol abstinence and a nutritionally balanced diet supplemented by all B vitamins.

However, in the setting of ongoing alcohol use, vitamin supplementation alone has not been convincingly shown to be sufficient for improvement in most patients. The present review is focused around the multiple pathways involved in the development of peripheral neuropathy associated with chronic alcohol intake and the different therapeutic agents which may find a place in the therapeutic armamentarium for both prevention and management of alcoholic neuropathy."

TO RULE OUT EACH FACTOR:

INVESTIGATIONS:

ANATOMICAL LOCATION OF THE PROBLEM:

• CREATININE KINASE  Levels are found to be normal -- NEUROMUSCULAR CONDITION ruled out
• SEROLOGY negative -- no VIRAL involvement
• THYROID PROFILE is normal -- THYROID MYOPATHY ruled out
• There is history of difficulty in holding chappals and wasting and thinning of muscles, difficulty in standing from sitting position, difficulty in climbing stairs -- so may be NERVE related.
• Chest x-ray and ECG are done for the most patients as general investigations to rule out other comorbid conditions and have a baseline ECG and chest x-ray.
• Neuromuscular junction disorder is ruled out as the electromyography is normasl in this case.
• There is HYPOTONIA,FLACCIDITY,HYPOREFLEXIA -- pointing towards LMN lesion
• Deep tendon reflexes 
                       Right.             Left
  Biceps.          P.                     ---
  Triceps.         ---                   ---
  Supinator.     ---                    ---
  Knee             ---                    ---
  Ankle.           ---                    ---
  Tone   ul.     normal.         Normal
            LL.  hypotonia.      hypotonia

     Power:almost all the muscles in the leg are showing 3/5 power indicating flaccid paralysis.

• Nerve involvement is confirmed by NERVE CONDUCTION STUDIES as it helps to know whether defect is in axon or myelin sheath.

The study shows: 

Bilateral common peroneal and sural nerve axonal neuropathy(peripheral neuropathy)

PHYSIOLOGICAL FUNCTIONAL DISABILTY:

 

There is axonal degeneration of neurons leading to functional disability of these nerves resulting in 

• progressive weakness or clumsiness
• difficulty in walking
• absence of reflexes or diminished

ETIOPATHOGENESIS:

 Referring to the link--

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370340/

DIAGNOSIS:

• Paraparesis secondary to peripheral neuropathy (bilateral common peroneal nerves and sural nerves).
• Scabies

TREATMENT:

• Pharmacological component
• T pcm 650 mg thrice daily for fever
• Inj neomol 100ml IV infusion if fever greater than 101° f
• T.bcomplex once daily for peripheral neuropathy
• Permethrin 5% lotion for scabies 

• Non-pharmacological component
• Physiotherapy and proper diet are recommended.

THANK YOU...

REFERENCES:

• https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

• https://ddxof.com/weakness/

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3370340/

ACTIVE LEARNING AND CONVERSATIONAL DISCUSSSION SUPPORT TO TREATING TEAM OF THIS CASE :

[5/22, 18:50] MBBS 2016 UG 3: 2) Presented by Dr Hitesh 2014 batch
https://hitesh116.blogspot.com/2020/05/elog-13th-may-2020.html?m=1

[5/22, 18:52] MBBS 2016 UG 3: Sir...in the case...can scabies be stated in the main complaints of the patient according to priority....because it was found on examination...not complained of by the patient

[5/22, 20:36] Post residency PG1: Yes
Logically main complaint is what the patient complains of
So if the patient complains mainly of paraparesis no point focusing much on scabies

[5/22, 20:48] MBBS 2016 UG 3: Ok sir👍