paraperesis

8/12/2019 Paraperesis

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Clinical features of Paraperesis


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MULTIPLE SCLEROSIS


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Patients with MS may present with many other

manifestations, including the following:

Aphasia or dysphasia (occurs very rarely)

Seizures (5% of patients with MS)

Other paroxysmal symptoms (eg, ataxia,

akinesia, paresthesias, pruritus) Significant motor complaints without sensory

deficits


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Fatigue

Fatigue is one of the most common symptom

of MS, reported by at least 75% of patientswith the disease.

An estimated 50-60% of persons with MS

describe fatigue as one of their mostbothersome symptoms, and it is a majorreason for unemployment among MSpatients.

Rule out comorbid medical conditions, such as infections, anemia, vitamindeficiencies (eg, vitamin B12, folic acid, vitamin D deficiency) or thyroid

disease, before attributing fatigue to MS.


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Optic neuritis

Optic neuritis can be the first demyelinatingevent in approximately 20% of patients with MS.

Approximately 40% of these patients develop

optic neuritis. Characterized by loss of vision in the affected eye

and pain on movement of the eye.

Much less commonly, patients get phosphenes

(transient flashes of light or black squares) lasting

from hours to months. Phosphenes may occur before or duringan ON event or even several months following recovery.


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Partial acute transverse myelitis is usually amanifestation of multiple sclerosis. Acute

partial loss of motor, sensory, autonomic,

reflex, and sphincter function below the levelof the lesion indicates acute transverse

myelitis.


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Spasticity

Is characterized by increased muscle tone and

resistance to movement; it occurs most

frequently in muscles that function to

maintain upright posture. The muscle stiffness

greatly increases the energy expended to

perform activities of daily living (ADLs), whichin turn contributes to fatigue.


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Cognitive dysfunction

May occur early in the course of disease. Areas of

cognition affected may include any of the following:

Comprehension and use of speech

Attention

Memory Visual perception

Planning

Problem solving

Executive function (ability to correctly followsequential steps)

Abstract reasoning


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Pain in MS can be classified as primary or secondary.

Primary pain is related to the demyelinating processitself. This neuropathic pain is often characterized ashaving a burning, gnawing, or shooting quality.

Secondary pain in MS is primarily musculoskeletal innature and possibly results from poor posture, poorbalance, or abnormal use of muscles or joints as aresult of spasticity.


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Constipation

Constipation is the most frequent bowelcomplaint in patients with multiple sclerosis

and is characterized as the infrequent ordifficult passage of stools.

N/B Multiple sclerosis patients withadvancing disability and impaired bladderfunction may experience recurrent urinarytract infections.


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Heat intolerance

Persons with MS often experience an increase

in symptoms of fatigue or weakness when

exposed to high temperatures due to weather,exercise, hot showers or baths, or fever.

May result in blurring of vision (Uhthoff sign),

usually in an eye previously affected by opticneuritis. They typically reverse rapidly when exposure to hightemperature ends.


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HEREDITARY SPASTIC PARAPLEGIA

hereditary spastic paraplegia (HSP) is a

group of clinically and genetically diverse

disorders that cause progressive and

generally severe lower extremity weaknessand spasticity.

After normal gestation, delivery, and early

childhood development, subjects develop legstiffness and gait disturbance (eg, stumbling,

tripping) because of difficulty in dorsiflexing

the foot and as a result of weakness in hip

flexion.


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The classic symptom of HSP is progressive difficulty in

walking. Some patients eventually may require the useof a wheelchair, while others may never need any typeof assistive device. Patients usually have difficulty lifting their toes;as a result, they drag their toes when walking and catch them on stairs oron uneven sidewalks or curbs.

In later stages, patients complain of reduced sensationin the distal regions of the legs.

Some people also experience urinary problems egincontinence or a sense of urgency even when thebladder is not full


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Decreased sense of balance

A common symptom that the patient firstnotices.

Most of these patients have an impaired

sense of foot position. If the brain does notreceive accurate signals relating to the body's

position, it may not be able to respond

properly to those signals, and loss of balanceoccurs.


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In complicated HSP, a rare disorder, additionalsymptoms may include the following:

Peripheral neuropathy Epilepsy

Ataxia

Optic neuropathy

Retinopathy

Dementia

Ichthyosis Mental retardation

Deafness

Problems with speech, swallowing, or breathing


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ADEM

Clinically, acute disseminated encephalomyelitis (ADEM) isusually readily distinguishable from multiple sclerosis(MS) by the presence of certain clinical features, includingthe following:

History of preceding infectious illness or immunization

Association with constitutional symptoms and signs suchas fever

Prominence of cortical signs such as mental statuschanges and seizures

Comparative rarity of posterior column abnormalities,which are common in MS

Age younger than 11-12 years in ADEM and age olderthan 11-12 years in MS


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The mean age at presentation is about 7 years.

Typical cases of ADEM arise 1-20 days after a childhood

infectious illness, which is febrile in more than 94% ofcases. There is usually a clearly defined phase of afebrile improvement

lasting 1-20 days or more before onset of neurologic findings.

Documentation of at least 1 fever-free day is especially

suggestive of ADEM. Occasionally, ADEM may occur in the wake of several

weeks of fever of unknown origin.

Some patients have back pain prior to the development

of ADEM-related inflammatory myelitis. Various vaccines have been suggested as the exogenous

provocation of cases of ADEM and may account for 3-6%of ADEM cases.

evidence exists for the role of the Pasteur rabies vaccine


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The first signs of ADEM usually include abruptonset of irritability and lethargy (>94% of

cases).The onset of neurologic abnormalities isabrupt in more than 95% of ADEM cases.Occasionally, the development of diffuse marked neurologic abnormalitiesrequires only a few hours

Changes in mental status (88% of cases) arecommonly observed in ADEM.

Convulsive seizures occur around the onset ofADEM in as many as 25% of cases.


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ADEM-associated optic neuritis is usually

bilateral, although the onset in a second eye may

follow onset in the first by days to months. Opticneuritis in MS is frequently unilateral.

A wide variety of cranial nerve abnormalitiesmay occur in addition to optic nerve disease.

Long tract signs (eg, clonus, increased musclestretch reflexes, upgoing toes) are present early

in as many as 80% of cases.


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Fairly symmetric leg weakness is seen in many cases ofADEM-related transverse myelitis with associatedabnormalities of bowel and bladder function.

Most ADEM presentations may be summarized into 7clinical syndromes as follows: Mild encephalopathy, sometimes associated with long tract

signs

Severe encephalopathy with bilateral paresis, often associated

with brainstem signs, particularly the lower cranial nerves Predominantly brainstem presentation with features suggesting

Fisher syndrome in some cases

Hemiparesis, ipsilateral long tract signs, with or without seizure

ADEM-associated ataxia is often associated with nystagmus,

extremity ataxia, and long tract signs EMRN: Encephalomyeloradiculoneuropathy is a syndrome that

combines upper and lower motor neuron signs. EMRN maymanifest recurrences.


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SPINAL CORD INFARCTION

Spinal cord infarction is usually marked by anacute onset, often heralded by sudden andsevere spinal (back) pain, which may radiatecaudad.

This is associated with bilateral weakness,paresthesias, and sensory loss. Loss ofsphincter control with hesitancy and inabilityto void or defecate becomes evident within a

few hours. The spinal cord stroke, either ischemic or

hemorrhagic, has an acute onset evolvingover minutes.


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Spinal Arteries


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Neurologic deficit may occur without pain, butmost (>80%) spinal infarcts are painful. The mimicof coronary ischemia is seen because of the

occurrence of chest pain, which may be severe.

Uncomplicated spinal cord infarction is most

commonly thoracic

and presents as acuteparaparesis or paraplegia, numbness of the legs,and inability to void.

The syndrome depends on the level of the cordlesion and may vary from mild or moderate andeven reversible leg weakness to quadriplegia.


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Fever is a warning ("red flag"); consider infectious origins ofa spinal cord syndrome, particularly acute bacterialmeningitis, and focal extramedullary spinal lesions

(eg, epidural and subdural abscess, granuloma)and viralmyelitis due to herpes simplex.

Many reports exist, whereby cases of spinal cord infarctionoccur due to complications of surgical procedures in whichhypotension and prolonged positioning may be prominentfactors.

Also, aortic surgeries, injections for foraminal nerve block

for epidural anesthesia, or even self-injection by the addictseeking an intravenous accesshave been reported inassociation with and may be a causative of spinal cordinfarction.


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TRANSVERSE MYELITIS

Signs and symptoms of transverse myelitis usually develop over afew hours and worsen over a few days. Depending on the cause,one or both sides of the body may be affected.

Typical signs and symptoms include:

Pain.Pain associated with transverse myelitis often beginssuddenly in your neck or back, depending on the part of your spinalcord that's affected. Sharp, shooting sensations may also radiatedown your legs or arms or around your abdomen.

Abnormal sensations.Some people with transverse myelitis reportsensations of numbness, tingling, coldness or burning. Some areespecially sensitive to the light touch of clothing or to extreme heator cold.

Weakness in your arms or legs.Some people with mild weaknessnotice that they're stumbling or dragging one foot or that their legsfeel heavy as they move. Others may develop paralysis.

Bladder and bowel problems.These problems may include anincreased urinary urge, urinary incontinence, difficulty urinating andconstipation.


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Thank you..


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