Blog 4: Quadriparesis case

Hello everyone.. I am Aditya Rayilla, an intern posted in medicine department and one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties. 

Lately we've been getting alot of CNS cases in our hospital, but most of the time we identify the etiology depending on the history and examination, here is a case that shows an ambiguity in diagnosis as the case history points towards one type of a lesion and the examination towards another. 

Here is the case presentation of a 40 YO lady with quadriparesis (predominantly paraparesis of lower limbs)

Case History 

c/o difficulty in walking since 20days and weakness of both upper limbs 

HOPI: pt was a/a 20 days ago after which she had a trauma due to slippage of footwear while working in an agricultural field, immediately after fall, pt was unable to stand and nearby workers lifted her and made her sit on a chair. After a while she could walk by herself to home  slowly and there after she was unable to sit and stand. She also had dragging type of pain in both the Lower limbs and tingling sensarions of both the Upper Limbs. From then she was unable to walk without support. 

H/O difficulty in mixing food (rice)

no h/o bowel and bladder incontinence/ seizure episode/ syncopal attacks 

no h/o palpitations/sob/pedal edema/ decreased urine output

no h/o fever/vomitings/loosestools/cough/cold/dyspesia/nasal regurgitation.

HISTORY OF PAST ILLNESS

Past h/o seizures 2 yeaes back, on oxcarbazepine 300mg/po/BD.

pt underwent consultation in khammam for weaknwss, where she was told she was suffering through hypokalmeia for which she received oral correction and discharged.

 no h/o 

DM, HTN, CAD, ASTHMA, TB, ANTIBIOTICS, HORMONES, RADIATION, BLOOD TRANSFUSION, SURGERIES. 

General examination:

Pallor ABSENT

Icterus absent 

No cyanosis clubbing lymphademopathy 

Dehydration Absent

Temp Afebrile

Bp 90/60mm hg

Pr   86bpm

Cvs s1 s2 hears no murmurs

Rs BAE+

P/a soft, non tender

Cns 

Speech:normal

cranial nerves ,motor system,sensory system (fine touch decreased), vibrations decreased crude touch, pain and temperature intact 

Motor examination:

                      Right          Left

Bulk: 

Inspection.      N.              N

Palpation.        N.             N

Tone: 

UL.                  N.               N

LL.                    N.             N

Power:

Neck muscle.    Good.   Good 

Upper Limb:

Shoulder: Flexion 4/5.    4/5

Extension.             4/5.     4/5 

Lateral rotaion:     4/5.     4/5 

Medial rotation:    4/5.     4/5 

Abduction:            4/5.      4/5 

Adduction:            4/5.     4/5 

Elbow: 

Flexion (biceps)    4/5.    4/5 

Extension (triceps)  4/5. 4/5

Lower Limb:

Ilio psoas.                3/5.   3/5

Gluteus max.           3/5   3/5

Adductor femoris.   3/5  3/5

Hamstrings.             3/5   3/5

Quadriceps.             3/5   3/5

Tibialis ant.             3/5     3/5

Tibialis post.           3/5.    3/5

Peroneii.                  3/5.    3/5

Gastrocnemius.     3/5.    3/5

Ex. Digitorum L.     3/5.    3/5 

Fl. Digitorum L.      3/5.    3/5

Ex. Hallucis L.        2/5.    2/5

Reflexes:

Superficial:

Abdominal.              --       --

Deep tendon reflexes:

Biceps:                     --          --

Triceps:                   --           --

Supinator:               --           --

Knee:                       --           --

Ankle:                      --           --

Plantar:                  m.         m

Sensory:

STT: Crude touch. +          +

Pain.                        +         +

Temp.                      +         +

Post. Dorsal

Fine touch.             DECREASED

Vibration.                --         --

Position.                 --          --

Treatment : 

1. PREAGABAM 75/PO/HS

2. T. MVT/PO/OD

3. T. PANTOP 40Mg/PO/OD

4. BP/PR/SP02/TEMP CHARTING 4TH HOURLY

5. Oxcarbazepine 300mg b.d 

 

           

INVESTIGATIONS

COMPLETE URINE EXAMINATION (CUE)

COLOUR  Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN Negative

SUGAR Negative

BILE SALTS Negative

BILE PIGMENTS Negative

PUS CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

Heamogram

HAEMOGLOBIN # 10.2gm/dl

TOTAL COUNT # 13,600

NEUTROPHILS 70

LYMPHOCYTES 23

EOSINOPHILS 03

MONOCYTES 04

BASOPHILS 00%

PCV # 30.7 vol %

MCV 91.0fl

Calculation MCH 30.2

MCHC 33.2

RDW-CV 12.8

RDW-SD44.4 fl

RBC COUNT # 3.38millions/cumm 

PLATELET COUNT 3.66

SMEAR

Normocytic normochromic

Leucocytosis

Adequate in number and distribution

HEMOPARASITES No hemoparesites seen

Light Microscopy

Normocytic normochromic blood

picture

with leucocytosis

AMORPHOUS DEPOSITS Nil

UREA 39

#CREATININE 1.3 mg/dl

URIC ACID 3.7

CALCIUM 10.0

PHOSPHOROUS 3.8

SODIUM 143mEq/L

POTASSIUM 3.9mEq/L

CHLORIDE104mEq/L

HCV- NEGATIVE

HbsAG NEGATIVE

HIV NON REACTIVE

CASE ANALYSIS:

In this case, the case history provides us that the onset of quadriparesis is of a sudden onset in origin which points towards any sort of damage to the cord as in cervical myelopathy or a myelopathy at the lumbar region, if this was the case then it would've presented as a UMN i.e the reflexes would've been exagerated and the tone would've been increased i.e hypertonia. But as we can see through the examination the tone was decreased in the lower limb, gait showed buckling and there was areflexia seen, due to this ambiguity, the neurologist had suggested an MRI. After the MRI and referral from the orthopedician it was concluded that the cause of the quadriparesis was more of an LMN porbably of a peripheral neurpathy type rather than of a myelopathy originated quadriparesis. 

The patient was discharged as their was no progression nor there was any retrogression and then requested to follow up after a few days. 

TAKE HOME LESSON: 

In general in the case of a CNS anomaly according to our neurologist the case history plays a major role in identifying the cause of the lesion which has to be confirmed through the examination. But sometimes the inability of the patient to recall the exact sequence of events or to express their problem leaves us with an ambiguous situation. The MRI had suggested us that there were vertebral problems, but the cns examination and after an orthopedician referral it was concluded that the Quadriparesis however is not linked to the abnormalities in the anatomy of the vertebrae which in turn could have caused a myelopathy. Thus it is important to give equal importance to the case history, examination and as well as the radiological evidence we acquire. 

Here is a link to the investigations, videos and pictures related to the case 

https://drive.google.com/folderview?id=12ta0Xiuvslsg2V_kCbOowBh3s_J5DJ24

Thank you.