• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
PLHA with Paraplegia
 

PLHA with Paraplegia

on

  • 2,112 views

 

Statistics

Views

Total Views
2,112
Views on SlideShare
2,102
Embed Views
10

Actions

Likes
0
Downloads
42
Comments
0

3 Embeds 10

http://smcphysiciansmeet.blogspot.com 6
http://smcphysiciansmeet.blogspot.in 3
http://www.slideshare.net 1

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    PLHA with Paraplegia PLHA with Paraplegia Presentation Transcript

    • Dr. Devendra Patil 1 st yr. PG (G.Med ) Govt Stanley Hospital and Medical College Chennai
      • Srinivasan 34/M , labourer , resident of Kilpauk came to GHTM with complains of:
      • Inability to feel and move his both lower limbs ……1 m
      • Lack of bladder control ……………………………1 m
      • HOPI:-
      • Pt health problems began around 10 months ago when he had
      • Cough with expectoration
      • Fever intermittent low grade evening rise 1m
      • Wt loss
      • He was diagnosed to be Sero positive in Anna Nagar Govt Hospital and referred to GH. (Feb ‘09)
      • There he was found to have CD4 count to be 62 (July ‘09 ) and pt was started on ART
      • D4t / 3tc / Nvp – Regimen
      • He was apparently alright for next 4 m when he developed
      • left sided chest pain:
      • dull aching
      • non radiating
      • not associated with sweating palpitations.
      • associated with back ache
      • Pt then developed increasing difficulty to move both lower limbs.
      • Initially left limb followed by right 10 days later
      • Initially difficulty to hold slippers followed by increasing difficulty to get up from sitting or squatting position
      • No involvement of upper limbs
      • No involvement of facial muscles, difficulty in speech ,swallowing
      • Currently he is not able to move his limbs and turn his position in bed
      • Pt also developed sensory complains in the form of
      • Decreased sensation of hot n cold water in both limbs below umbilicus
      • Numbness in both limbs initially distal progressing proximally
      • Loss of pain sensation
      • h/o cotton-wool like sensations while walking on floor
      • No complains in the upper limbs
      • No h/o unnoticed trauma leading to ulcerations
      • No h/o root pains
      • No h/o radiculopathies
      • No h/o increasing back pains in night ( night cries )
      • No h/o any girdle like sensations
      • Pt developed urinary incontinence and retention of urine for which he was catheterised in GH.
      • Increasing difficulty in passing stools.
      • No h/o flexor spasms
      • No h/o headache , vomiting altered behavior or loss of consciousness
      • No h/o fever
      • No h/o trauma
      • No h/o TB in past but uncle died due to TB.
      • No h/o similar complains in past
      • No waxing and waning pattern seen
      • No h/o similar complains in family members
      • No h/o HTN or DM
      • Family H/o :-
      • On examination:-
      • He is conscious oriented , thin built , fairly hydrated and afebrile
      • T- afebrile
      • P- 97 / min
      • BP- 110/ 90 mm Hg
      • RR – 14/min
      • CNS:-
      • HMF : WNL
      • CN :- WNL
      • Motor :
      Bladder catheter present Pale Oral candidasis , pressure sores present non icteric , no cyanosis clubbing lymphadenopathy right left bulk reduced reduced tone decreased Decreased Power: UL LL 5/5 1/5 5/5 1/5 Superficial Reflexes Abdomen Cremaster Plantar Present Lost Withdrawl Present Lost Withdrawl Deep Reflexes Upper limbs ++ ++ Knee ankle + - + -
      • Motor:
      • No involuntary movements
      • No fasciculations
      • Co-ordination couldn’t be checked in LL
      • Head raising:-
      • Upper part of rectus contractions felt
      • Beevor sign:- not present
      • Sensory :
      • No sensory loss in Upper limbs and upper trunk
      • Decrease in sensation of touch and pain in both LL upto the level just above umbilicus ( T9 )
      • Sacral sparing present
      • Joint sense
      • Joint position decreased in both lower limb joints
      • Vibration
      • No level of hyeraesthesia noted
      • Cerebellar signs:-
      • WNL in UL . Couldn’t check in LL
      • Meningeal signs :- Absent
      • Spine :- no spinal deformity, Paraspinal muscle rigidity or paraspinal swelling, scars , sinuses,tenderness Skin over spine -normal
      • RS:-
      • Air entry B/L equal
      • Few crepitations present in Left lung in inter scapular regions.
      • P/A:- Soft. Non tender. No palpable organomegaly
      • CVS :- S1 , S2 present.No murmur.
      • PROBLEMS:-
      • PLHA on ART
      • Paraplegia
      • B/L Spino thalamic involvement
      • B/L Dorsal column involvements
      • Spinal myelopathy at Approximate level T9
      • ( Both motor and sensory )
      • Early Autonomic involvement
      • Possibly intramedullary or non- compressive nature
      • Probable Eitology being : TB - spine
      • In neuronal shock stage
      • Pulmonary TB
      • Hb : 7.4 gm %
      • TC : 4100 cells/cm
      • DC : N-69,L-18,M-13
      • Platelet : 2.17 L
      • RBC: 2.83 L
      • PCV : 32
      RBS : 95 BUN : 16 Sr. Cr. : 0.5 Sr. Bilirubin : 0.5 SGOT : 52 SGPT : 38 SAP : 313 Sr. Protein : 5.7 Sr. Albumin : 2.1 Sr. Globulin : 3.6 Sputum : positive 1+ HIV Elisa :- +ve CD4 : 62 ( July 2009 ) Hbs Ag : -ve ( Oct 2009 ) Anti HCV : -ve ( Oct 2009 ) USG Abdo :- Splenomegaly
    •  
    •  
    •  
    •  
    •  
    •  
    •  
      • MRI Findings:-
      • Hyperintense lesions noted intramedullary at D2- D3 and D8-D9 level in T2-weighted images most consistent with a granuloma.
    • Final Diagnosis
      • PLHA
      • Most likely
      • Potts paraplegia Grade IV.
      • To r/o disseminated TB
    • POTT’s Paraplegia
      • TB affection of spine with neurological involvement
      • Incidence : 20 % of all Pott’s Spine cases.
      • Radiological evidence :
      • X-ray- reduction in disc space
      • -destruction of vertebral body
      • - evidence of cold abscess
      • - rarefaction of surrounding vertebrae.
    • POTT’s PARAPLEGIA
      • Early onset Paraplegia:
      • -Inflammatory causes :-
      • -- Abscess
      • -- Granulation tissue
      • --Posterior spinal disease
      • --Infective thrombosis of spinal artery
      • - Mechanical Causes :-
      • --Sequestrum in canal
      • --Degenerated disc prolapse
      • -- ridge of bone pressing
      Late onset Paraplegia internal gibbus fibrous septae recurrence
      • Grade I - no symptoms only signs
      • Grade II – clumsiness , incordination , spasticity. Manages to walk with minimum support. No sensory complaints.
      • Grade III – not able to walk. Paraplegia in extension. Partial sensory loss.
      • Grade IV – paraplegia in flexion. Sphincter disturbances. Complete loss of sensation.
      • Finally : Flaccid Paraplegia
      GRADES OF POTT’s PARAPLEGIA
    • TREATMENT:
      • ATT
      • Immobilization of Spine
      • Physiotherapy to paralyzed limbs
      • Care about pressure sores
      • General health build up
      • Operative decompression Procedure
        • Operative indications :-
        • Paraplegia getting worse or no improvement .
        • Severe paraplegia
        • Sudden onset paraplegia
        • Cauda equina syndrome
        • Recurrent paraplegia
        • Painful paraplegia
        • Procedures done
        • Antero – lateral decompression
        • Costo – transversectomy
        • Radical debridement and spine stabilization
        • Laminectomy
    • THANK - YOU