PLHA with Paraplegia

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PLHA with Paraplegia

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

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