Transverse Myelitis ,24yr Male

Chief complaints:-

A 24yr male who is a agricultural labourer came with complaints of Weakness of All limbs ( LL > UL ) , Urinary retention since 3 days.

HOPI:- Patient is apparently asymptomatic 3 days back when he woke up at early morning 6am noticed weakness & Numbness in all limbs ( Lower limbs > upper limbs) due to which he is unable to roll or sit or get down the bed by himself so called his father for help. With 2 people support he's able to walk for few metres .He also notice weakness in upper limbs however he is able to do his activities with mild difficult.H/o Lower abdominal fullness and difficulty in passing urine. Pt is able to perceive sensation of bladder stones but unable to pass urine for which he visited a local hospital and got catheterised following which urine drained.

H/o fever 2 weeks back , moderate grade lasted for 2days subsided by taking OTC Medication.

H/o Tight band like sensation above the level of nipples.

H/o constipation from 2days however passing flatus.

No h/o fluctuations in weakness

No h/o weight loss, decreased appetite, night sweats. ( TB )

No h/o vision blurring, vomiting ( NMO )

No h/o Altered sensorium, seizures (ADEM)

No h/o recent vaccination.

No h/o trauma.

No h/o oral ulcers, dry mouth Behcets)

No h/o of rash on Face ( SLE )

No h/o dry cough, SOB ( Sarcoidosis)

PAST HISTORY:-

No significant past history

No h/o Animal bite/ vaccination

No h/o blood transfusion

FAMILY HISTORY:-

No h/o similar complaints in family members

PERSONAL HISTORY:-

Diet- vegetarian , Takes egg🥚

Sleep- Adequate

No addictions /high risk behaviour

SUMMARY:-

A 24 yr old male with out any pre existing comorbidity developed Acute progressive Quadriparesis ( LL > UL ) UMN type associated with decreased pain, Temp, vibration & joint position sensation below the level of T4 & feels a band like sensation at this level along with bladder & bowel involvement without HMF or cranial nerve involvement.

Anatomical structures:-

Posterior column

Spinothalamic tract

Corticospinal tract

Autonomous fibres.

Probably spinal cord at cervical level.

GENERAL PHYSICAL EXAMINATION:-

Pt is conscious/ alert/ cooperative

Facies- Normal

Built- moderate

Nutrition- BMI- 30kg/m2

Decibitus- Legs extended at Hip, knee & plantar flexed

PICCLE - Absent

PR- 86bpm, regular, normal volume, no radio radial or radio femoral delay

BP- 130/80mmhg in supine

RR- 16cpm, Thoraco abdominal type

Temp- 98.6f

No engorged neck veins/ enlarged neck glands/ no oral ulcers / no neuro cutaneous markers

Cranium & spine normal, No vertebral tenderness noted.

HIGHER MENTAL FUNCTIONS:-

Pt is rt handed

GCS- 15/15

Conscious/ well Oriented to time place & person.

Memory- Immediate, recent, remote intact.

Speech- Normal

CRANIAL NERVES:-

Normal

MOTOR:-

Muscle bulk preseved in all limbs.

No fasciculations/ wasting seen.

Attitude-

Pt lying supine position with attitude of both lower limbs extended at Hip , knee & flexed at ankle

Both arms placed at sides

TONE-

According to modified ashworth scale

Normal in U/L

Grade 1 Spasticity in L/L

POWER-

UPPER LIMB:- 4+/5 4+/5

LOWER LIMB:- 3/5. 3/5

REFLEXES:-

Rt. Lt

B. 3+. 3+

T. 3+. 3+

S. 3+. 3+

K. 3+. 3+

A. 3+. 3+

PLANTAR B/L extensor

SENSORY:-

spino thalamic

Crude touch,Pain,Temperature

She feels burning sensation below xiphisternum to feet & can't perceive any other

Post.column:-

Fine touch, Vibration,Proprioception- Decreased from C3 level to down.

CEREBELLUM:-

no nystagmus, giddiness, FNF- normal

HKT- couldn't be tested

GAIT- couldn't be tested since even with 2 people support she couldn't walk & has her both legs stiff

MENINGEAL SIGNS:-

Absent

Functional Diagnosis:- An young male with Acute progressive Quadriparesis , UMN type with sensory both large & small fibre, CST at Upper cervical cord level with bladder & bowel involvement without HMF,CN, Involvement.

Anatomical Diagnosis:-

Quadriparesis with B&B #

S/o Spinal cord #

Brisk DTR's with B/L Extensor plantars - Corticospinal tract #

Impaired proprioception & vibration, pain & temp below C3 level:- Large fibre & small fibre involvement.

Pathological diagnosis:-

Acute rapidly progressive nature- probably Demyelination, vascular

Etiological diagnosis:-

NMOSD

TB,Post infectious,

Idiopathic

Less likely - B12, Cu & Vit E def.

ANS:-

Resting tachycardia, abnormal sweating absent

OTHER SYSTEMS:-

CVS:- Apex beat in left 6th ICA 1cm medical to mid clavicular line

S1S2 heard no murmers

No raised jvp, engorged veins

RS:-

Bae+, Nvbs, No added sounds

ABDOMEN:-

Soft, non tender, no organomegaly

DIFFERENTIAL DIAGNOSIS:-

With the above history I would like to localize the lesion to Dorsal spinal cord at the level of T4 since it started acutely & involving most of the tracts probably Non compressive myelopathy.

Demyelinating ( MS / NMOSD )

Vitamin Deficiency - B12

Vascular

Infective

Para infectious

Investigations:-

MRI Cspine with WSS with contrast with brain and Optic nerve screening - LETM ( Cervical ,thoracic cord involvement with enhancement with Normal Brain & Optic Nerves)

Rx:-

Pluse steroids 1gm in 250ml NS over 4hrs for 5days.

Pt's LL power improved from 3/5 to 4/5 & discharged with Oral steroids 1mg/kg & advised to review after 2 weeks.

Every 2 week's Tapering steroids by 10mg

Bladder function isn't attained even after 2mnths of discharge so he's placed on silicon foleys Catheter.

He complained of Spasticity & tightness in limbs so T.Oxetol 150mg 1----0----1 is added & later escalated to 300mg BD, Since it persisted Propranolol 40mg is added along with Gabapin NT 100/10 BD

Patient couldn't void spontaneously so he's placed on Silicon Foleys Catheter.

URODYNAMIC STUDIES:-