A 51-year-old male farmer presented with recurrent mid back pain and weakness in both lower limbs three months after thoracic spine surgery and anti-tubercular treatment (AKT) for tuberculosis. He developed fever, anorexia, and weakness after the local physician modified his AKT drugs. On examination, he had flaccid paraparesis below D8 level with reduced sensations and reflexes in both lower limbs along with bowel and bladder involvement. Differentials included failure of AKT, multi-drug resistant tuberculosis, superadded infection, or HIV-TB based on his recurrent symptoms and modification of treatment.

1. ASSI CASE PRESENTATION
Dr Siddharth Katkade
Sancheti Hospital, Pune

2. Chief complaints:
• 51/ male, farmer, resident of Jalgaon, Maharashtra came with
complaints of;
1. Mid back pain with right girdle pain since 3 weeks
2. Weakness in both lower limbs since 2 weeks

3. HOPI:
• Patient was apparently alright 3 months back when he started c/o mid back pain
with left girdle pain and acute onset complete loss of bilateral lower limb power.
• For which he was hospitalized and underwent spine surgery at thoracic level and
was started on AKT
• After 1 month of AKT patient had h/o fever, anorexia, halitosis, generalized
weakness for which he had consulted local physician who had modified AKT
drugs
• Over a period of 2 months post surgery patient showed clinical recovery in the
form of decrease mid back and girdle pain and gradual improvement in b/l lower
limb power and started walking with support.

4. HOPI:
• Post 2 months of surgery,
-patient started c/o mid back pain which was insidious in onset,
gradually progressive and dull aching in nature. Aggravated with sitting,
standing, walking and relieved on lying supine. Its was associated with
right girdle radiation which was sharp shooting type and intermittent
initially which progressed to continuous pain.

5. HOPI:
• Post 2.5 months of surgery,
-patient started developing weakness in right f/b left lower limb.
Insidious in onset and acutely progressed from proximal to distal lower limb
which made him non walker since a week.
At present,
-patient is unable to stand and walk
-unable to log roll or sit in bed independently
-using bed pan and diaper for urination and defecation

6. • There is h/o change in AKT treatment by local physician
• h/o evening onset fever, anorexia, generalized weakness, halitosis
• h/o constipation and urinary hesitancy and incomplete voiding
• No h/o
-trauma/fall
-discontinuation/ missed AKT treatment
-visual or hearing issues
• No h/o
-Headache, convulsions
-Cough, expectoration
-abdominal/flank pain, blood or pus in urine
• No h/o
-post operative blood transfusion
-any long term medications other than AKT

7. Treatment history:
• Apart for spine surgery and AKT medications no other treatment taken

8. • Past history : no other medical co morbidities
• Personal history :
-h/o chronic alcohol consumption of 180 ml per day for last 5 years and
occasionally before that
-h/o chronic tobacco consumption since 15 years
• Family history : no h/o TB/HIV contact in family

9. Clinical summary:
• 51 years, male
- with recurrent onset mid back and right girdle pain
- with acutely progressing bilateral lower limb weakness with bowel
bladder involvement
- With h/o thoracic spine surgery 3 months back with AKT
- With history of modification in AKT by local physician in view of
fever, anorexia, generalized weakness and halitosis

10. Diagnosis based on history:
• 51 years, male with 3months postoperative recurrent acute onset
paraparesis secondary to,
differentials:
- Failure of AKT or
- Multi drug resistant tuberculosis or
- Superadded pyogenic/fungal infection or
- HIV-TB

11. Examination:
• General examination:
-Patient is conscious, oriented to time place person
-Averagely built and well nourished
Pulse – 84/min
BP – 130/70 mm Hg
Respiratory Rate – 20/ min
SpO2- 98% on room air

12. -Pallor +
-Icterus +
-No oedema
-No lymphadenopathy
-No clubbing
• Systemic examination:
-CVS- S1,S2 heard and normal
-RS- Air entry equal bilaterally
-Per abdomen- soft non tender, no organomegaly, bladder not palpable

13. Spine Examination:
Gait: Cannot be assessed
Inspection:
From front, side and back in supine and lateral position in well lit room
From front:
- Head - shoulder- pelvis appears align in center
- no chest asymmetry
- Iliac crest, patella and medial malleolus appears at same level

14. From side:
No exaggerated cervical/thoracic/lumbar curves
From back:
Midline Surgical scar present extending from spine of scapula till
dorsolumbar junction
No fullness/swelling seen around the neck, over chest and abdominal
wall, over proximal thigh, gluteal region or popliteal fossa
No skin lesions or ulcers seen
Conjunctivitis and icterus +

15. Palpation:
All inspector findings are confirmed on palpation
No local rise in temperature
Deep, thrust tenderness present over scar at the level of angle of
scapula
Right sided paraspinal tenderness and bilateral para spinal muscle spasm
present at same level

16. Cannot be assessed
Movements and Measurements:

17. Neurological Examination:
• Higher cranial functions – normal
• Cranial nerves examination – normal
• Cerebellar examination (diadochokinesia and finger to nose test) –
normal
• Motor system:
- Nutrition:
Right (cm) Left (cm)
Mid Arm 32 31
Mid Forearm 23.5 23
Mid Thigh 44 42
Mid calf 30 31

18. -Tone:
-Power:
-Involuntary movements: absent
Right (cm) Left (cm)
Upper limb Normal Normal
Lower limb Flaccid Flaccid
Right (cm) Left (cm)
Upper limb 5/5 5/5
Lower limb
Hip flexion 0 0
Knee extension 2 2
Ankle dorsiflexion 0 0
EHL & EDL 0 0
Ankle plantarflexion 2 2

19. -Sensory:
-Reflexes:
Perianal sensations - decreased
Anal tone – decreased
Voluntary anal contraction – weak
Sensations
Touch, pain, temperature Reduced below D8 dermatome
Proprioception Absent
Vibration Reduced
Superficial Deep
Abdominal – absent Biceps +2
Triceps +2
Supinator +2
Cremastric – absent
Plantars – extensor Knee – absent
Ankle – absent
Clonus – absent

20. • SI joint, Hip and knee joint examination – normal
• Distal pulsations – present
• Diagnosis:
51 years, male with 3 months postoperative recurrent acute onset flaccid
paraparesis with bowel bladder involvement with neurological level of
D8 secondary to,
- Failure of AKT or
- Multi drug resistant tuberculosis or
- Superadded pyogenic/fungal infection or
- HIV-TB