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TB Myeloradiculopathy
- 37/M presented with acute onset paraparesis and paresthesia of both lower limbs that progressed over 1 week and has been static for 3 months - He has a history of HIV/AIDS on ART and treated disseminated TB 1 year ago - Exam shows flaccid paraparesis, sensory loss from L1, absent reflexes from C5-S1, and bladder involvement but no bowel involvement - Differential includes infectious myeloradiculopathy (TB, HIV, CMV) or acute CIDP - Investigations and management are planned including MRI, LP, immunological workup and immunosuppression
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TB Myeloradiculopathy
- 1. GENERAL CLINICS July, 2021 Dr.Manievelraaman Kannan 3rd year PG Prof. Dr. C. Hariharan’s Unit M1 IIM, MMC & RGGGH
- 2. HISTORY Mr. Kannappan 37/Male;Right-handed person; Weaver from Thirutthani Chief complaints: • C/O Inability to use both lower limbs X 3 months
- 3. HISTORY OF PRESENTILLNESS • Pt was apparently normal 3 months back. • Pt then developed weakness of bilateral lower limbs (in the form of inability to raise from squatting position in restroom) • Acute onset • Progressed over 1 week to attain nadir • Duration – 3 months
- 4. • H/O Inabilityto stand from squatting position + • H/O Inability to climb stairs + • H/O Buckling of knees while walking with support + • H/O Dragging of feet while walking with support + • H/O difficulty in gripping slippers + • H/O Heavy sensation of legs + • H/O Thinning of both lower limbs + • No H/O Muscle twitches • No H/O Fluctuation or diurnal variation of symptoms • No H/O difficulty in turning in bed from side to side • No H/O difficulty in lifting head from pillow
- 5. • H/O Pinsand Needles sensation in foot while walking + • Able to feel hot and cold water while bathing present • Able to feel his clothing + • Able to feel bed under his body + • Able to feel mosquito bites in LL + • No H/O cotton wool like sensation in foot while walking on barefoot • No H/O fall while washing face (wash basin sign) • No H/O Electric shock like sensation while bending neck • NO H/O LOW BACK ACHE • No H/O GIRDLE SENSATION IN THE TRUNK
- 6. • No H/Oany difficulty in using both upper limbs • No H/O swaying to sides while standing • No H/O Bowel disturbance (able to feel fullness, initiate and control bowel movements and No H/O constipation) • H/O Bladder disturbance + (urinary urgency) • No H/O Impotence • No H/O dizziness immediately after assuming erect posture from recumbent posture • H/O decreased sweating present in both legs +
- 7. • No H/Oany involuntary movements • No H/O LOC, Altered sensorium, Seizures, Loss of memory, perceptual disturbances, difficulty in speech/reading/writing • No H/O altered smell sensation • No H/O visual disturbances • No H/O double vision, eyelid drooping • No H/O abnormal sensation over the face / chewing difficulty • No H/O deviation of angle of mouth, drooling of saliva, inability to close eyes, inability to raise eyebrows
- 8. • No H/Ohearing disturbances / ringing sensation in ears • No H/O difficulty in swallowing, change in voice, nasal regurgitation of food particles, dysarthria • No H/O difficulty in shrugging shoulders / turning head sidewards • Able to protrude tongue • No H/O Fever / Neck rigidity / Headache / Vomiting / Trauma • H/O Loss of Weight + • H/O Loss of Appetite +
- 9. PAST HISTORY • NoH/O similar episodes in the past • K/C/O Retroviral disease on ART (TLE) for last 1 year • K/C/O Miliary TB / ?TBM – diagnosed around 1 year back and treated with ATT (2HRZE + 6HRE) for 8 months and then stopped for last 2 months • Not a K/C/O SHTN, DM, CAD, CKD, CLD, Epilepsy • No H/O recent vaccination / dog bite • No H/O blood transfusion / tattooing
- 10. PERSONAL HISTORY • Mixeddiet consumer • Smoker - occasional • Alcoholic – occasional • Tobacco (Hans) chewing habit + • No H/O IV drug abuse • Married – No offspring • No H/O Extramarital affairs • No H/O similar illness running in his family
- 11. SUMMARY • 37/M –K/C/O RVD+ & Disseminated TB (Miliary + ?TBM) on ART and ATT for last 1 year • Has come with C/O Acute onset Paraparesis along with Paresthesia, which progressed to nadir over 1 week and then remained static in that level for last 3 months. • Involvement of Bladder • No involvement of Bowel • Probable system involved: Nervous system ( Motor + Sensory + ?ANS ) • Probable structure involved: Root + Spinal Cord • Probable pathology: Infective
- 12. GENERAL EXAMINATION • Conscious •Oriented • Afebrile • Comfortable at rest / Co-operative • Thin built and under nourished • Mild Pallor + • No Icterus / Cyanosis / Clubbing / LN / Dependent edema • Dry skin with ichthyotic patches present in lower half of both legs and foot • Sacral sore (healed) + • Hypopigmented macules + (few scattered in trunk and limbs) • No Neurocutaneous markers, No nerve thickening
- 13. VITALS • Temperature: Normal •PR: 90/min, regular, normal volume and character, felt in all peripheral vessels, no radio- radial or radio-femoral delay, no vessel wall thickening • RR: 14/min; Abdominothoracic • BP: 110/70 measured in RA in sitting posture • 110/70 in LA • 120/70 in both LL • JVP: not elevated
- 14. NERVOUS SYSTEM EXAMINATION •HIGHER MENTAL FUNCTIONS • Conscious • Oriented to Time / Place / Person • Memory (Immediate, Recent, Remote) intact • Intelligence normal • Speech and language normal • Affect normal • Sleep normal • MMSE – 25/30
- 15. • CRANIAL NERVEEXAMINATION RIGHT LEFT OLFACTORY NERVE Perceive & Identify smell Normal Normal OPTIC NERVE Acuity/Field/Color vision Normal Normal 3,4,6 CN EOM/Pupil size/Light reflex/Accommodation reflex Nystagmus/Ptosis Normal Nil Normal Nil TRIGEMINAL NERVE Sensations on the face Clenching of teeth Opening of mouth Corneal/Conjunctival reflex Jaw jerk Normal Normal Normal Normal Not exaggerated Normal Normal Normal Normal Not exaggerated
- 16. RIGHT LEFT FACIAL NERVE SENSORY(TASTE ANT 2/3RD TONGUE) MOTOR FOREHEAD WRINKLING EYE CLOSURE BLOWING CHEEKS OBLITERATION OF NASOLABIAL FOLD CORNEAL/CONJUNCTIVAL REFLEX Normal Normal Normal Normal Absent Normal Normal Normal Normal Normal Absent Normal 8th CN RINNE TEST WEBER TEST AC>BC NOT LATERALISED AC>BC NOT LATERALISED IX & X CN POSITION OF UVULA GAG REFLEX MIDLINE PRESENT
- 17. XI CN SHRUGGING SHOULDERS TURNINGHEAD SIDE TO SIDE Normal Normal Normal Normal XII CN TONGUE PROTRUSION WASTING FASCICULATION/TREMOR Normal Absent Absent Normal Absent Absent
- 18. • MOTOR EXAMINATION •BULK: UL • BULK: LL • TONE: RIGHT LEFT ARM 21cm 21cm FOREARM 18cm 18cm THIGH 31cm 31cm LEG 21cm 21cm Upper Limb Normal Normal Lower Limb Decreased Decreased
- 19. • POWER: UPPER LIMBRIGHT LEFT SHOULDER ABDUCTION ADDUCTION FLEXION EXTENSION 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 ELBOW FLEXION EXTENSION 5/5 5/5 5/5 5/5 WRIST FLEXION EXTENSION 5/5 5/5 5/5 5/5 FINGER FLEXION/EXTENSION ABDUCTION/ADDUCTION 5/5 5/5 5/5 5/5
- 20. • POWER: LOWER LIMBRIGHT LEFT HIP ABDUCTION ADDUCTION FLEXION EXTENSION 0/5 0/5 0/5 0/5 0/5 0/5 0/5 0/5 KNEE FLEXION EXTENSION 0/5 0/5 0/5 0/5 ANKLE PLANTAR FLEXION DORSIFLEXION 0/5 0/5 0/5 0/5 TOES FLEXION/EXTENSION ABDUCTION/ADDUCTION 1/5 1/5 1/5 1/5
- 21. • REFLEXES • WARTENBERGSIGN POSITIVE IN BOTH UPPER LIMB • NO PRIMITIVE REFLEXES SUPERFICIAL REFLEXES RIGHT LEFT CORNEAL + + CONJUNCTIVAL + + PHARYNGEAL + + ABDOMINAL - - CREMASTERIC - - PLANTAR Equivocal Equivocal BULBOCAVERNOUS - - DEEP TENDON REFLEXES RIGHT LEFT BICEPS Absent Absent SUPINATOR Absent Absent TRICEPS Normal Normal KNEE Absent Absent ANKLE Absent Absent
- 22. • SENSORY EXAMINATION •PERIANAL SENSATION: DECREASED • ROMBERG SIGN COULD NOT BE TESTED; CORTICAL SENSATION NORMAL IN UL RIGHT LEFT TOUCH UL: NORMAL TRUNK: NORMAL JUST UPTO INGUINAL LIGAMENT (T12) LL: GRADED LOSS UL: NORMAL TRUNK: NORMAL JUST UPTO INGUINAL LIGAMENT (T12) LL: GRADED LOSS VIBRATION UL:NORMAL TRUNK:LOST BELOW ASIS LEVEL LL:GRADED LOSS UL:NORMAL TRUNK:LOST BELOW ASIS LEVEL LL:GRADED LOSS PROPRIOCEPTION/ JOINT POSITION SENSE UL: NORMAL LL: LOST UL: NORMAL LL: LOST PAIN UL: NORMAL TRUNK: NORMAL JUST UPTO INGUINAL LIGAMENT (T12) LL: GRADED LOSS UL: NORMAL TRUNK: NORMAL JUST UPTO INGUINAL LIGAMENT (T12) LL: GRADED LOSS TEMPERATURE (HOT & COLD) UL: NORMAL TRUNK: NORMAL JUST UPTO INGUINAL LIGAMENT (T12) LL: GRADED LOSS UL: NORMAL TRUNK: NORMAL JUST UPTO INGUINAL LIGAMENT (T12) LL: GRADED LOSS
- 23. • CEREBELLAR EXAMINATION •NO INVOLUNTARY MOVEMENTS • GAIT COULD NOT BE TESTED • NO SIGNS OF MENINGEAL IRRITATION: NO NECK RIGIDITY, KERNIG’S & BRUDZINSKI’S NEGAVTIVE • SPINE AND CRANIUM NORMAL; NO GIBBUS, DEFORMITY; NO SPINAL TENDERNESS. RIGHT LEFT FINGER NOSE TEST NORMAL NORMAL FINGER FINGER NOSE TEST NORMAL NORMAL RAPID ALTERNATING MOVEMENTS NORMAL NORMAL LL COULD NOT BE TESTED COULD NOT BE TESTED
- 24. OTHER SYSTEM EXAMINATION •CVS: • S1 S2 + • No murmur • RS: • NVBS • BAE+ • No added sounds • ABDOMEN: • Soft, non tender • No organomegaly
- 25. SUMMARY • 37/M –K/C/O RVD+ & Disseminated TB (Miliary + ?TBM) on ART and ATT for last 1 year • Has come with C/O Acute onset Flaccid Paraparesis along with Paraesthesia, which progressed to nadir over 1 week and then remained static in that level for last 3 months. • Motor system is affected from L1-S1 • Sensory: Graded loss of sensation from Inguinal ligament region L1 • Reflexes lost from C5-C6 and L1-S1 • Involvement of Bladder (UMN type) • No spinal tenderness • No involvement of Bowel • No involvement of cerebellum; Spine, Cranium & Meninges: Normal
- 26. DIAGNOSIS • A caseof Acute onset of symmetric Flaccid Paraparesis and Paraesthesia with bladder involvement without the evidence of cranial nerve involvement • Site of Lesion: Myeloradiculopathy • Motor level: L1 • Sensory: Graded loss of sensation from L1 below • Reflexes lost from C5-C6 and L1-S1 • Autonomic level: Above S2 • Probable Aetiology: Infective > Inflammatory • Differential Diagnosis: • Infective Myeloradiculopathy (?TB/?HIV/?CMV) • Acute onset of CIDP
- 27. INVESTIGATIONS • Routine Investigations-CBC, RFT, LFT, Electrolytes • CE-MRI LS Spine with WSS with • NCS and VEP • CSF – Cell count, Proteins, Sugar, LDH, ADA, GeneXpert, IgM CMV, CMV DNA PCR, IgG HTLV-1 • Blood- CD4 count, IgM CMV • B12 and Folate levels, Peripheral smear • CT Brain and CT Chest
- 28. MANAGEMENT • ATT • ART •Acyclovir or Ganciclovir (if applicable) • IVIg 2g/kg in divided doses over 2-5 days • PE 2-3 times/week for 6 weeks • Glucocorticoids 60-80mg Prednisolone for 1-2 months • Immunosuppressants: Azathioprine, MTX, Cyclosporine, Cyclophosphamide • Rituximab • High Protein diet, Limb physiotherapy, Frequent position changes, Water/Alfa Bed, Bladder and Bowel care
- 29. 1 year backNow
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