return of the trouble
DESCRIPTION
A case presentation made by me at OSMECON-2014 recorded in our hospital.TRANSCRIPT
RETURN OF THE TROUBLE-
TUBERCULOUS ARACHNOIDITIS WITH SYRINGOMYELIA-A CASE REPORT
BY-
Akash Srivatsav T
Moderated by-
Dr.N.V.Sundarachary MD;DM
Dr.U.Veramma MD;DM
Dr.R.Lalitha MD.
Name Mr.GCSR
Age 47 years
Sex Male
Marital status Married with a child
Occupation Shopkeeper
Address Guntur
Regd no A030616
DOA 14-07-2014
DOD 21-07-2014
Patient Particulars
Chief symptoms of-
.
• Weakness of both lowerlimbs since six months
• Weakness of both upperlimbs for three months.
• Tingling, numbness and paraesthesias of two months duration.
• Bladder diturbances of two months duration
History Of Present Illness
• Weakness of both the lower limbs in the form
of inability to getup from sitting and
Squatting positions, climbing up-stairs, auto-rikshaw
and bus which was associated with stiffness.
Weakness of both hands while
performing fine finger movements like
mixing food and writing for three
months.
Tingling, numbness and paraesthesias of both
hands and feet for three months which was first
observed in the feet with no subjective loss of
sensations.
Girdle sensation around the upper trunk below
the nipples.
Micturition disturbances like urgency,frequency,overflow incontinence.
Sexual dysfunction in the form of erection and
ejaculation difficulties
No history of
• Speech and language disturbances,
• Disturbances of higher mental functions in any form,
• Cranial nerve involvement in any form,
• Weakness of proximal upperlimb and distal lowerlimb musculature.
No history suggestive of-
• Involvement of cerebellum and meninges,
• Raised IntraCranial Tension,
• Gait disturbances.
Past history
• Diagnosed to have TB meningitis 20 years ago and received ATT for 2 years.
• Underwent lumbar laminectomy 20 years back.
General condition on examination-
Conscious, coherent and oriented.
Moderately built and nourished
No- PallorIcterus
CyanosisClubbingLymphadenopathyPedal oedma
Vitals-
Afebrile
BP-130/80 mm of Hg
PR-78/min
RR-16/min
CNS examination-
Right hand dominant
Speech and language – Normal
Higher mental functions- Normal
Cranial nerves- Normal
Motor examination
Bulk –Normal in all the four limbs
Tone- Spasticity of all the four limbs
Muscle group Right Left
Shoulder 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Abduction 5/5 5/5
Adduction 5/5 5/5
Elbow 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Wrist 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Hand grip 90 % 90 %
Power -
Upper Limbs
Lower limbs
Muscle group Right Left
Hip 4/5 4 /5
Flexion 4/5 4/5
Extension 4/5 4/5
Abduction 4/5 4/5
Adduction 4/5 4/5
Knee 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Ankle 5/5 5/5
Dorsi flexion 5/5 5/5
Plantar flexion 5/5 5/5
EHL Normal Normal
EDL Normal Normal
Reflexes
Deep Tendon
Reflexes
Biceps Triceps Supinator Knee Ankle
Right 3 + 3+ 3+ 3 + Absent
Left 3+ 3+ 3+ 3+ Absent
Plantar : Bilateral Equivocal
Superficial reflexes – Present
Sensory Examination
Cutaneous – Pain and Temperature intact
Joint position sense and vibration – Absent in all the four limbs*In upper limbs till the wrist joints*In lower limbs upto the knees
Loss of vibration upto – T4 vertebral level
No meningeal signs
No signs of raised ICT
Provisional Diagnosis
Spastic quadriparesis with peripheral
neuropathy
Differential diagnosis
• Spinal tuberculosis
• Other causes of myelopathy.
INVESTIGATIONS :
Investigation Result
Hb % 10.2gm/dL
RBS 78mg%
ESR 40mm in 1st hr
Blood Urea 14mg%
Serum Creatinine 0.8mg%
Sodium 157mEq/L
Potassium 4.1mEq/L
Chloride 126mEq/L
HIV I Non reactive
HIV II Non reactive
HbsAg Negative
HCV Negative
CSF Analysis
Total Count : 696 cells/cumm
Differential Count : Neutrophils - 80Lymphocytes- 20
Protein : 855 mg/dL
Glucose : 100mg/dL
PANDYS : Positive
ADA – CSF Fluid : 0.9 U/L
PCR for TB antigen : Positive
IMAGING
STUDIES
MRI of whole spine
• Syrinx extending from C3 to D11 with maximum diameter measuring 5.8mm in the dorsal region.
• Status post laminectomy at L4 - L5 level.
• Bilateral facetal hypertrophy at L4 – L5 level.
• Posterior central protrusion at L4 – L5 level causing impingement over the thecalsac with narrowing of bilateral neural foramina causing compression over the exciting nerve roots.
• Crowding of thecal sac at L4 level with increased epidural fat at this level.
• Loculation of CSF opposite from D4 to D6 level on the posterior aspect.
Features represent syrinx with associated sequelae of arachnoiditis.
Nerve conduction studies-
Decreased CMAP amplitudes.
Absent F-waves
Absent SNAPs
Axonal motor sensory polyradiculoneuropathy .
Final diagnosis
Type-III-C Syringomyelia
Extending from C3-D11 with
tuberculous arachnoiditis leading to
Polyradiculoneuropathy.
Treatment• Tab Rifampicin 600mg OD• Tab Isoniazide 450mg OD• Tab Pyrazinamide 750mg BD• Tab Ethambutol 1000mg OD• Tab Prednisolone 1mg/kg body wt in tappering
doses• Tab Tolperisone hydrochloride 150mg OD• Tab Pyridoxine 40mg OD• Tab Calcium OD• Syp Potassium
Outcome
• The patient reported improvement of
I. Tingling, numbness and parasthesias of hands and feet.
II. Weakness of the upper and lower limb musculatures.
III. Micturition disturbances.
DiscussionTuberculosis remains one of the
treatable but troublesome disorders affecting central
nervous system.
A high index of suspicion and detailed evaluation revealed the presence of a coexisting, medically treatable condition in the patient who also had syringomyeliawhich however did not explain his symptomatology.
Also surgery is deferred in our patient.
Conclusion
Tuberculous arachnoiditis resulting in syringomyelia is a
rare and late complication. Our patient has recurrence of
tuberculosis which produced the clinical picture .Indepth
knowledge of the pathophysiology and meticulous workup are
the cornerstones in successful management of such cases .
Bibliography
• Adams and Victor's Principles of Neurology, Ninth Edition
• Bradley's Neurology in Clinical Practice, 6th ed.