plha with paraplegia

Dr. Devendra Patil1st yr. PG (G.Med )

Govt Stanley Hospital and Medical College Chennai

Srinivasan 34/M , labourer , resident of Kilpauk came to GHTM with complains of:

Inability to feel and move his both lower limbs ……1 m

Lack of bladder control ……………………………1 m

HOPI:-Pt health problems began around 10 months

ago when he hadCough with expectorationFever intermittent low grade evening rise

1mWt loss

He was diagnosed to be Sero positive in Anna Nagar Govt Hospital and referred to GH. (Feb ‘09)

There he was found to have CD4 count to be 62 (July ‘09 ) and pt was started on ART

D4t / 3tc / Nvp – RegimenHe was apparently alright for next 4 m when

he developed left sided chest pain:

dull aching non radiating

not associated with sweating palpitations.

associated with back ache

Pt then developed increasing difficulty to move both lower limbs.

Initially left limb followed by right 10 days later

Initially difficulty to hold slippers followed by increasing difficulty to get up from sitting or squatting position

No involvement of upper limbs No involvement of facial muscles,

difficulty in speech ,swallowing Currently he is not able to move his

limbs and turn his position in bed

Pt also developed sensory complains in the form of Decreased sensation of hot n cold water in both

limbs below umbilicus Numbness in both limbs initially distal

progressing proximally Loss of pain sensation h/o cotton-wool like sensations while walking on

floor No complains in the upper limbs No h/o unnoticed trauma leading to ulcerations No h/o root pains No h/o radiculopathies No h/o increasing back pains in night ( night

cries ) No h/o any girdle like sensations

Pt developed urinary incontinence and retention of urine for which he was catheterised in GH.

Increasing difficulty in passing stools.

No h/o flexor spasms No h/o headache , vomiting altered behavior or loss of consciousness No h/o fever No h/o trauma No h/o TB in past but uncle died due to TB. No h/o similar complains in past No waxing and waning pattern seen No h/o similar complains in family members No h/o HTN or DM

Family H/o :-

On examination:-He is conscious oriented , thin built , fairly hydrated and afebrile

T- afebrileP- 97 / minBP- 110/ 90 mm HgRR – 14/min CNS:-HMF : WNLCN :- WNLMotor :

right left

bulk reduced reduced

tone decreased Decreased

Power: UL LL

5/51/5

5/51/5

Superficial ReflexesAbdomenCremasterPlantar

PresentLostWithdrawl

PresentLostWithdrawl

Deep ReflexesUpper limbs ++ ++

Kneeankle

+-

+-

Bladder catheter presentPale Oral candidasis , pressure sores presentnon icteric , no cyanosis clubbing lymphadenopathy

Motor:No involuntary movementsNo fasciculationsCo-ordination couldn’t be checked in LLHead raising:-Upper part of rectus contractions feltBeevor sign:- not present

Sensory :No sensory loss in Upper limbs and upper trunkDecrease in sensation of touch and pain in both LL upto

the level just above umbilicus ( T9 )Sacral sparing presentJoint senseJoint position decreased in both lower limb jointsVibration No level of hyeraesthesia noted

Cerebellar signs:- WNL in UL . Couldn’t check in LL

Meningeal signs :- Absent

Spine :- no spinal deformity, Paraspinal muscle rigidity or paraspinal swelling, scars , sinuses,tenderness Skin over spine -normal

RS:-Air entry B/L equalFew crepitations present in Left lung in inter scapular

regions.

P/A:- Soft. Non tender. No palpable organomegaly

CVS :- S1 , S2 present.No murmur.

PROBLEMS:-

PLHA on ARTParaplegiaB/L Spino thalamic involvementB/L Dorsal column involvementsSpinal myelopathy at Approximate level T9 ( Both motor and sensory ) Early Autonomic involvement Possibly intramedullary or non- compressive natureProbable Eitology being : TB - spineIn neuronal shock stagePulmonary TB

Hb : 7.4 gm %TC : 4100 cells/cmDC : N-69,L-18,M-

13Platelet : 2.17 LRBC: 2.83 LPCV : 32

RBS : 95BUN : 16Sr. Cr. : 0.5

Sr. Bilirubin : 0.5SGOT : 52SGPT : 38SAP : 313Sr. Protein : 5.7Sr. Albumin : 2.1Sr. Globulin : 3.6

Sputum : positive

1+

HIV Elisa :- +veCD4 : 62 ( July 2009 )Hbs Ag : -ve ( Oct 2009 )Anti HCV : -ve ( Oct 2009 ) USG Abdo :-

Splenomegaly

MRI Findings:- Hyperintense lesions noted

intramedullary at D2- D3 and D8-D9 level in T2-weighted images most consistent with a granuloma.

Final Diagnosis

PLHA Most likelyPotts paraplegia Grade IV. To r/o disseminated TB

POTT’s Paraplegia

TB affection of spine with neurological involvement

Incidence : 20 % of all Pott’s Spine cases.

Radiological evidence :X-ray- reduction in disc space

-destruction of vertebral body- evidence of cold abscess- rarefaction of surrounding vertebrae.

POTT’s PARAPLEGIA Early onset Paraplegia:

-Inflammatory causes :-

-- Abscess

-- Granulation tissue

--Posterior spinal disease

--Infective thrombosis of spinal artery

- Mechanical Causes :-

--Sequestrum in canal

--Degenerated disc prolapse

-- ridge of bone pressing

Late onset Paraplegiainternal gibbusfibrous septae recurrence

Grade I- no symptoms only signs Grade II – clumsiness , incordination ,

spasticity. Manages to walk with minimum support. No sensory complaints.

Grade III – not able to walk. Paraplegia in extension. Partial sensory loss.

Grade IV – paraplegia in flexion. Sphincter disturbances. Complete loss of sensation.

Finally : Flaccid Paraplegia

GRADES OF POTT’s PARAPLEGIA

TREATMENT:

ATT Immobilization of Spine Physiotherapy to paralyzed limbs Care about pressure sores General health build up Operative decompression Procedure

Operative indications :-

Paraplegia getting worse or no improvement . Severe paraplegia Sudden onset paraplegia Cauda equina syndrome Recurrent paraplegia Painful paraplegia

Procedures doneAntero – lateral decompressionCosto – transversectomyRadical debridement and spine stabilizationLaminectomy

THANK -

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