CASE REPORT

SPASTIC INFERIOR PARAPARESE WITH

HIPESTESIA FROM THE TIP OF TOES TO ONE

FINGER BELOW PROCESSUS XIPHOEDEUS

SENIOR CLINICAL CLERKSHIP

Period of October 28th – December 2nd , 2013

By :

Arazy Gifta Prima 04124705087

Muhammad Hadi Wijaya 04124708039

Aji Kusuma 04124708058

Advisor : Dr. H. A. Rachman Toyo, Sp.S(K)

DEPARTMENT OF NEUROLOGY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY

MOHAMMAD HOESIN GENERAL HOSPITAL

PALEMBANG

2013

ENDORSEMENT PAGE

Case Report

SPASTIC INFERIOR PARAPARESE WITH

HYPOESTHESIA FROM THE TIP OF TOES TO ONE FINGER BELOW

PROCESSUS XIPHOEDEUS

Presented by:

Arazy Gifta Prima

04124705087

Muhammad Hadi Wijaya

04124708039

Aji Kusuma

04124708058

Has been accepted as one of requirements in undergoing senior clinical clerkship period of

October 28th – December 2nd 2013 in Department of Neurology Faculty of Medicine Sriwijaya

University Mohammad Hoesin General Hospital Palembang.

Palembang, November 2013

Advisor

Dr. H. A. Rachman Toyo, Sp.S(K)

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NEUROLOGY MEDICAL RECORD

IDENTIFICATION

Name : Ms. FDAge : 28 years oldSex : FemaleOccupation : StudentAdmitted : October 3rd, 2013 at 07.10 am

ANAMNESIS

Patient was admitted to the hospital due to weakness of both legs.

1 month before admission, patient complains of heaviness when moving her legs. She also complains about pain in her spine. She feels the heaviness on her legs became more severe each day. She denied any sensibility disorders, previous seizures, headache, nausea, crooked smile or impaired talking.

She has a history of a productive cough for over a month which is accompanied by shortness of breath, night perspiration and decreasement of body weight. She has been diagnosed with tuberculosis and has recieved tuberculosis treatment for 10 days before admitted to the hospital. She denied any history of trauma, falling, lifting heavy objects, stroke, diabetes, hypertension or heart diseases.

This is the first time the patient presents these symptoms.

PHYSICAL EXAMINATION

PRESENT STATEInternal State

Conciousness : CM (E4M6V5)Nutrition : SufficientTemperature : 37.7 oCPulse : 78 beats/minRespiratory rate : 28 times/minBlood pressure : 110/80 mmHg

Psychiatric stateAttitude : CooperativeAttention : Normal

Neurological stateHead Shape : BrachicephalySize : NormalSymetric : YesHematome : No

Heart : No abnormalityLungs : crackles (+) in both lungsLiver : No abnormalitySpleen : No abnormalityExtremities : See neurological stateGenital : No abnormality

Facial Expression : Natural Psychological contact : Natural

Deformity : NoFracture : NoFracture pain : NoVessel : No widening

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Tumor : NoNeck Position : StraightTorticolis : NoNape of neck stiffness : No

Pulsation : No disorder

Deformity : NoTumor : NoVessels : No widening

CRANIAL NERVESN.I: Olfaktorius nerve SmellingAnosmiaHyposmiaParosmia

N.II: Opticus nerve Visual acuityCampus visi

Anopsia Hemianopsia

Oculi fundus Edema papil Atrophy papil Retina bleeding

N.III: Occulomotorius , N.IV: Trochlearis , and N.VI: Abducens nerves DiplopiaEyes gapPtosisEyes position

Strabismus Exophtalmus Enophtalmus Deviation conjugae

Eyes movementPupil

Shape Size Isochor/anisochor Midriasis/miosis

Light reflex direct consensuil accommodation

Argyl Robertson

RightNo disorder

NoNoNo

Right6/6 PH (-)

V.O.D

NoNo

NoNoNo

RightNoNoNo

NoNoNoNo

No abnormality

RoundØ 3mm

IsochorNo

PositivePositive Positive

No

LeftNo disorder

NoNoNo

Left6/6 PH (-)

V.O.S

NoNo

NoNoNo

LeftNoNoNo

NoNoNoNo

No abnormality

RoundØ 3mm

IsochorNo

PositivePositivePositive

No

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N.V: Trigeminus nerve Motoric

Biting Trismus Corneal reflex

Sensory Forehead Cheek Chin

N.VII: Facialis nerve MotoricFrowningEyes closingGigglingNasolabial foldFacial shape

rest Speaking/whistling

Sensory 2/3 anterior tounge

Autonomy Salivation Lacrimation Chvostek’s sign

N.VIII: Statoacusticus nerve Cochlearis nerveWhisperingHour tickingWeber testRinne testVestibularis nerveNystagmusVertigo

N.IX: Glossopharingeus , and N.X: Vagus nerves Pharyngeal archUvulaSwallowing disorderHoarsing/nasalisingHeart beatReflex

Vomiting Coughing Occulocardiac Caroticus sinus

Sensory 1/3 posterior tounge

RightNo disorder

NoYes

NormalNormalNormal

RightSimetricNormal

NormalNormal

No disorderNo disorder

No disorder

No disorderNo disorderNo disorder

RightNo disorderNo disorder

Normal Normal

NoNo

RightNo disorderNo disorder

NoNo

Normal

No disorderNo disorderNo disorderNo disorder

No disorder

LeftNo disorder

NoYes

NormalNormalNormal

LeftSimetricNormalNormalNormal

No disorderNo disorder

No disorder

No disorder No disorderNo disorder

LeftNo disorderNo disorder

Normal Normal

NoNo

LeftNo disorderNo disorder

No No

Normal

No disorderNo disorderNo disorderNo disorder

No disorder

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N.XI: Accessorius Nerve Shoulder RaisingHead Twisting

N.XII: Hypoglossus Nerve Tounge ShowingFasciculationPapil AthrophyDysarthria

MOTORICArmsMotionPowerTonesPhysiological Reflex

Biceps Triceps Radius Ulna

Pathological Reflex Hoffman Tromner Leri Meyer Trofik

LEGMotionPowerTonesClonus

Thigh Foot

Physiological reflex K P R A P R

Pathological reflex Babinsky Chaddock Oppenheim Gordon Schaeffer Rossolimo Mendel Bechterew

Abdominal skin reflex Upper Middle Lower Tropik

RightNo disorderNo disorder

RightNo deviation

NoNoNo

RightSufficient

5Normal

NormalNormalNormalNormal

NegativeNegativeNegativeNegative

RightLack

2Increase

PositivePositive

Increase Increase

PositivePositiveNegativeNegativeNegativeNegativeNegative

NegativeNegativeNegativeNegative

LeftNo disorderNo disorder

LeftNo deviation

NoNoNo

LeftSufficent

5Normal

NormalNormalNormalNormal

NegativeNegativeNegativeNegative

LeftLack

2Increase

PositivePositive

IncreaseIncrease

PositivePositiveNegativeNegativeNegativeNegativeNegative

NegativeNegativeNegativeNegative

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SENSORYHypoesthesia from the tip of the toes to one finger below processus xiphoedeus

PICTURE

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VERTEBRAL COLUMN

Kyphosis : Yes Tumor : NoLordosis : No Meningocele : NoGibbus : Yes, Vertebrae T6-7 Hematome : NoDeformity : No Tenderness : No

SYMPTOMS OF MENINGEAL IRRITATION

Nape of neck stiffnessKerniqLassequeBrudzinsky

Neck Cheek Symphisis Leg I Leg II

RightNoNoNo

NoNoNoNoNo

LeftNoNoNo

NoNoNoNoNo

GAIT AND BALANCEGait Balance and CoordinationAtaxia : Can not be assesed Romberg : Can not be assessedHemiplegic : Can not be assesed Dysmetri : Can not be assessedScissor : Can not be assesed finger – finger : Can not be assessedPropulsion : Can not be assesed finger nose : Can not be assessedHisteric : Can not be assesed heel - heel : Can not be assessedLimping : Can not be assesed Reboundphenomenon : Can not be assessedSteppage : Can not be assesed Dysdiadochokinesis : Can not be assessedAstasia-Abasia : Can not be assesed Trunk Ataxia : Can not be assessed

Limb Ataxia : Can not be assessed

ABNORMAL MOVEMENTSTremor : NoChorea : NoAthetosis : NoBallismus : NoDystoni : NoMyoclonus : No

VEGETATIVE FUNCTIONMicturition : No abnormalityDefecation : No abnormality

LIMBIC FUNCTIONMotoric aphasia : NoSensoric aphasia : NoApraksia : NoAgraphia : NoAlexia : NoNominal aphasia : No

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LABORATORY FINDINGSBLOOD (24th October 2013)Hb : 11.7 gr/dl (12-16)Erythrocyte : 4.670 mil/mm3 (4.0-5.0)Hematocrit : 35 vol% (37-43 vol%)Leucocyte : 13500/mm3 (5000-10000)LED : 38 mm/hour (<38)Thrombocyte : 513000/mm3 (200.000-500.000)Diff Count : 0/1/0/62/10/7 (0-1/1-3/2-6/50-70/20-40/2-8)Total cholesterol : 97 mg/dl (<200) Ureum : 23 mg/dl (15-39)Uric acid : 4 mg/dl (5,7-14)Creatinin : 0.39 mg/dl (0,6-1,0)SGOT : 102 U/l (<40)SGPT : 88 U/l (<41)Na : 132 mmol/l (135-155)K : 3.9 mmol/l (3,5-5,5)Calcium : 8,2 mg/dl (8,8 – 10,2)

URINE (25th October 2013)Epithel : ++ Protein : -Leucocyte : 3-5 Glucose : -Eritocyte : 0-2

FECESConsistency : Not performed Erytrocyte : Not performed Slime : Not performed Leucocyte : Not performed Blood : Not performed Worm egg : Not performed Amoeba coli : Not performed Hystolitica : Not performed

CEREBRO SPINAL FLUID (30th October 2013)MacroscopicVolume : 0,5 ccColour : colourlessClarity : clearOdor : odorlessMass : 1020Sediments : negativePH : 9

MicroscopicLeucocyte count : 1Diff.count : PMN : 0, MN : 100Blast cell : negativeNonne : NegatifPandy : NegatifProtein : 1,1 g/dlLDH : 82 u/LGlucose : 38 mg/dl

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Chloride : 113 mEq/l

SPECIFIC EXAMINATIONCranium X- Ray : Not performedChest X- Ray (October 24th 2013) : consolidation of both lungsVertebral column X- Ray (October 30th 2013) : spondylitis TB of VT9Electroencephalography : Not performedElectroneuromyography : Not performedElectrocardiography : Not performedArteriography : Not performed Pneumography : Not performedHead CT-Scan : Not performed

RESUME

IDENTIFICATIONName : Ms. FDAge : 28 years oldSex : FemaleOccupation : StudentAdmitted : October 3rd, 2013 at 07.10 am

Ms. FD, female, 28 years, admission date 3rd of October 2013

ANAMNESIS

Patient was admitted to the hospital due to weakness of both legs.

1 month before admission, patient complains of heaviness when moving her legs. She also complains about pain in her spine. She feels the heaviness on her legs became more severe each day. She denied any sensibility disorders, previous seizures, headache, nausea, crooked smile or impaired talking.

She has a history of a productive cough for over a month which is accompanied by shortness of breath, night perspiration and decreasement of body weight. She has been diagnosed with tuberculosis and has received tuberculosis treatment for 10 days before admitted to the hospital. She denied any history of trauma, falling, lifting heavy objects, stroke, diabetes, hypertension or heart diseases.

This is the first time the patient presents these symptoms.

PHYSICAL EXAMINATION

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Conciousness (GCS score) : GCS 15 (E4 M6 V5)

Blood pressure : 110/80 mmHg

Pulse rate : 78 x/m

Respiration rate : 28 x/m

Temparature : 37.7 C

Neurological examination:

N III : round pupil, isokor, Light reflex +/+, diameter 3 mm

N VII : symmetrical plica nasolabialis

N XII : no tongue deviation

Motoric function Right trunk Left trunk Right arm Left arm

Movement Good Good decreased decreased

Power 5 5 2 2

Tonus n n ↑ ↑

Klonus + +

Physiological ref n n ↑ ↑

Pathological ref - - +BC +BC

Sensory function : hypoesthesia from the tip of the toes to one finger below processus

xiphoedeus

Limbic function : no disorders

Vegetative function : no disorders

Meningeal signs : -

Abnormal movements : -

Gait dan balance : could not be assessed yet

Local status :

- Gibbus on the spinal cord, localized at T6-7 and T10

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LABORATORY FINDINGSBLOOD (24th October 2013)Hb : 11.7 gr/dl (12-16)Erythrocyte : 4.670 mil/mm3 (4.0-5.0)Hematocrit : 35 vol% (37-43 vol%)Leucocyte : 13500/mm3 (5000-10000)LED : 38 mm/hour (<38)Thrombocyte : 513000/mm3 (200.000-500.000)Diff Count : 0/1/0/62/10/7 (0-1/1-3/2-6/50-70/20-40/2-8)Total cholesterol : 97 mg/dl (<200) Ureum : 23 mg/dl (15-39)Uric acid : 4 mg/dl (5,7-14)Creatinin : 0.39 mg/dl (0,6-1,0)SGOT : 102 U/l (<40)SGPT : 88 U/l (<41)Na : 132 mmol/l (135-155)K : 3.9 mmol/l (3,5-5,5)Calcium : 8,2 mg/dl (8,8 – 10,2)

URINE (25th October 2013)Epithel : ++ Protein : -Leucocyte : 3-5 Glucose : -Eritocyte : 0-2

CEREBRO SPINAL FLUID (30th October 2013)MacroscopicVolume : 0,5 ccColour : colourlessClarity : clearOdor : odorlessMass : 1020Sediments : negativepH : 9

MicroscopicLeucocyte count : 1Diff.count : PMN : 0, MN : 100Blast cell : negativeNonne : negatifPandy : negatifProtein : 1,1 g/dlLDH : 82 u/LGlucose : 38 mg/dlChloride : 113 mEq/l

SPECIFIC EXAMINATIONChest X- Ray : consolidation of both lungsVertebral column X-ray : spondylitis TB of VT9

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DIAGNOSISClinical diagnosis :

Spastic inferior paraparese

hypoesthesia from the tip of the toes to one finger below processus xiphoedeus

Topical diagnosis : total tranvese lesion of medula spinalis T 6-7

Ethiology diagnosis : suspected tuberculosis spondylitis

MANAGEMENTNon-pharmacology : Low sodium diet

O2 3 liter

Pharmacology : IVFL NaCL gtt XX/menit Inj. ceftriaxone vial 2 x 1 g Ranitidine amp 2 x 1 Paracetamol tab 3 x 500 mg Ambroxol syr 3 x 1 c Vitamin B1, B6, B12 tab 3x1 Inj tramadol 3x1 amp Rifampisin tab 450 mg 1 x 1 Isoniazid tab 300 mg 1 x 1 Pirazinamid tab 500 mg 2 x 1 Etambutol tab 750 mg 1 x 1

Planning : Consult to Internal Medicine MRI vertebrae Physiotherapy

PROGNOSISQuo ad vitam : Dubia ad bonamQuo ad functionam : Dubia ad malam

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CASE ANALYSIS

Differential Diagnosis of Etiology:

Paraparese

a. Paralysis of UMN lesionCharacteristics:

Hypertonus Hyperflexion Patology reflex (+) Muscle atropy (-)Examples: Spondylitis T.B., S.O.L., trauma, Infection

b. Paralysis of LMN lesionCharacteristics:

Hypotonus, clonus (-) Hyporeflex Atropy degenerative: muscle atropy (+), fast onset 1-2 weeks Patology reflex (-)Examples: trauma, carpal tunnel syndrome, Gullain Barre syndrome, radiation, toxin or poison, demyelinating disease.

c. Paralysis combination (nuclear lesion + UMN/LMN lesion)Characteristics:

Fascicular contraction (+) Muscle atropy Hypertonus, often clonus (+) Hyperreflex Patology reflex (+)Examples: ALS, myelin syndrome.

In conclusion, this patient’s paralysis is due to an UMN lesion.

Hypoesthesia

a. Spinal cord lesion : distinct and symmetric sensory level distribution of hypoesthesia

b. Thalamic lesion : complete hemibody distribution of hypoesthesiac. Brain stem lesion : incomplete hemibody distribution of hypoesthesia

In conclusion, this patient’s hypoesthesia is due to a spinal cord lesion

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Etiology :Medula Spinalis Contussion

Symptoms of the patient:

Risk Factors :- trauma

Symptoms :- acute and permanent weakness

Supporting Examination :- CT-Scan :

- trauma (-) 

- chronic and progressive weakness  

- CT-Scan :

The etiology of Medula Spinalis Contussion should be RULED OUT

Etiology :Myelitis

Symptoms of the patient:

Risk Factors :-

Symptoms :- fever- Subacute manifestation- Rigid neck and low back pain- Symmetrical motoric disorder

Supporting Examination :- CT scan

   

- Head injury (-) 

- fever (-)- subacute manifestation (+)- Rigid Neck and low back pain (-)- Symmetrical motoric disorder (+)

- CT-Scan :

The etiology of Myelitis should be RULED OUT

Etiology :Tuberculosis Spondylitis

Symptoms of the patient were:

Risk Factors :- History of chronic infection such as TB

Symptoms :- vertebrae destruction- Chronic Progressive Weakness

Supporting Examination :- Blood examination : leucocytosis- CSF : muddy; increasing cells, glucose

and protein

  

- History of TB infection (+) 

- vertebrae destruction (+)- Chronic progressive weakness (+)

- Leucocytosis (+)- CSF : increasing MN cells, glucose, and protein

The etiology of Tuberculosis Spondylitis is POSSIBLE

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