PARAPARESIS OF THE LOWER LIMBS SECONDARY TO TB

Paraparesis of the lower limbs.

Hello all, I am P.Vihar (Roll no 127) a student of 8th semester pursuing medicine at KIMS Narketpalli. Today I share, in this blog my views and thoughts on a case which our department of general medicine has shared, to help us achieve better understanding of the clinical cases.

The link given below, is to the entire case details :-

• https://vaish7.blogspot.com/2020/05/medicine.html?m=1

MY VIEWS AND THOUGHTS ON THIS CASE.

Here we see a 23 year old male patient with history of a sudden fall when he tried to get up to use the bathroom.

Patient came to the hospital in this regard complaining of weakness in both lower limbs.

After going through his history i have some questions in mind which i will write down below:-

1) His chief complaint was tingling and numbness in both lower limbs since 5 days.

This makes me think of paresthesia in his legs, but when we talk about paresthesia there are many causes like herniated disc, tumor in the spinal cord, etc.. all of which have one thing in common some kind of pathology in the nerve supplying the effected region. (most commonly this is pressure on the nerve)

2) He has a history of multiple sexual partners 

And has a history of a gluteal and a scrotal abcess.

This brings to mind sexually transmitted diseases. Among the plethora of STDs that a person can get, only a few have an association with his neurological symptoms like syphilis, or secondary infection of the spine post development of AIDS.

Patients with syphilis may develop scrotal abcess too, as it is famously known to mimic various diseases.

Keeping the abcesses in mind a HIV infection is definitely a contender (suggesting a weak immune system allowing secondary infections which in turn may effect the spinal nerves) , but it doest really explain his neurological symptoms directly. Also when tested for HIV he was negative and he showed no other signs of being HIV positive. (weight loss, skin infections, etc...)

3) He has hypotonia in both his legs. 

And reduced power as well (left < right).

This is once again in line with neurological involvement. At this point the patient must be asked in detail about any trauma to spine or any chronic pain in the back, and so on to rule out common causes of his symptoms such as, herniated disc, trauma to spinal cord, etc...

4) When tested for reflexes it was noticed that he had 3 very brisk responses on his right and 3 cases of slightly reduced responses on his left side respectively. (this is not necessarily abnormal but I thought its worth mentioning) Another rather unusual sign noted was his right ankle was positive for an ankle clonus.

Now seeing this i think of a right sided UMN and left sided LMN but this is quite uncommon.

How can we explain the (presumably) slightly exaggerated reflexes on his right and slightly reduced reflexes on his left??

After a little digging I thought of ALS which can show both a UMN and LMN symptoms simultaneously.

ALS also called motor neurone disease and it exists in mainly 3 clinical varieties:-

CLASSICAL ALS                                                 (affects both cranial and spinal motor nerves)

PRIMARY LATERAL SCLEROSIS                                   (affects upper motor neurones only)

PROGRESSIVE MUSCULAR ATROPHY                         (affects lower motor neurones only)

In our case the best contender would be classical ALS of spinal onset. (it accounts for almost 67 percent of classical ALS cases, which in turn account for about 70 percent of ALS cases)

Classical ALS of spinal onset, as the name suggests begins by affecting the spinal motor neurones first and later on affects the upper motor neurones.

But we must remember that the +3 and +1 graded reflexes need not be abnormal in the first place. But it is safe to keep this as a differential because of existence of seemingly both UMN and LMN simultaneously.

DETAILS ON ALS

5) Upon routine investigations he was found to have an elevated ESR and ALT AST ALP levels.

We can interpret this an infection, this further supports the syphilis differential we've previously established. But there is always a possibility of this being sign to another infection.

6) Upon examining his radiological signs we notice,

Multiple nodules at the apex of the lungs - a sign of infection,

Diffuse enhancement in the MRI images of his brain, suggesting a breech in the BBB, yet another sign of infection (of the brain)

Firstly talking about the nodules noticed at the apex of the lungs this suggests TB, but can be explained by syphilis as well. (but the nodules in syphilitic lung infection were mostly found at the basilar regions) lung nodules in syphilis

The MRI findings could be due to either of the contenders, syphilis or tuberculosis. As we know neurosyphilis to occur at a late stage in syphilis, we must ask him a detailed history of his sexual life and any lesions on his genitals at a earlier stage in life.

Similarly in order to rule out TB we must ask for a detailed history as well.

BASED ON THE CLINICAL FINDINGS AND HIS HISTORY I HAVE COME UP WITH A DIFFERENTIAL AS FOLLOWS:-

• TUBERCULOSIS
• SYPHILIS 
• AMYOTROPHIC LATERAL SCLEROSIS

CONSIDERING TB-

• The differential Tuberculosis explains the nodules in the apex of his lung
• The MRI signs 
• His raised ESR and other signs of infection 
• His paraparesis as a complexion of POTTS DISEASE affecting his lumbar vertebrae. (POTTS DISEASE is commonly seen in lower thoracic and upper lumbar vertebrae)
• The abscess are not explained by this differential, but there is a possibility of them being unrelated conditions as well.

CONSIDERING ALS OF SPINAL ONSET-

• ALS explains his neurological symptoms
• But does not account for his signs of infection, the abscess and the nodules in his lungs.

CONSIDERING SYPHILIS-

(It is a known fact that he has multiple sexual partners,

further supporting this differential)

• The syphilis accounts for the abscess
• The lung nodules*** (not exactly as the nodules in syphilis are basilar) 
• The MRI signs 
• Raised ESR and other signs of infection
• His paraparesis can be explained by a late stage symptom of syphilis called TABES DORSALIS, which is a type of neurosyphilis.

IN BOTH TB AND SYPHILIS IT IS IMPORTANT TO NOTE THAT THE NEUROLOGICAL SIGNS NOTED IN THIS CASE APPEAR ONLY IN THE LATTER STAGES OF BOTH THESE DISEASES, THEREFORE ID SUGGEST A HISTORY DATING FURTHER BACK TO LOOK INTO BOTH THE DIFFERENTIALS.

It is quite common in people with multiple sexual partners to not approach a healthcare provider when they first notice certain symptoms, and opt for self treatment (which often grossly inadequate) based on their self research. That is what i suspect has happened in this case.

I would suggest a test for TB and SYPHILIS to achieve a final diagnosis and treat for the same.