The Curious Cases of Paraparesis - Case 2
ACTIVE LEARNING CONVERSATION AROUND A 23 YEAR-OLD-MALE WITH COMPLAINTS OF WEAKNESS IN BOTH LOWER LIMBS :
(Kindly note, the key learning points have been highlighted in ORANGE and GREEN below)
Case 2:
"[5/23, 10:06 AM] mbbs 2016 UG1: Sir, what symptoms made us suspect TB in this case? How did we confirm the diagnosis of TB in this case?
https://vaish7.blogspot.com/2020/05/medicine.html?m=1
[5/23, 10:11 AM] PG Post residency PG1: Go through this active learning discussion and let me know if you still don't have the answer.
https://medicinedepartment.blogspot.com/2020/05/frequently-asked-questions-around-case.html?m=1
Then we can add our active learning discussion to it around this question
[5/23, 10:11 AM] mbbs 2016 UG1: I went through it sir.
[5/23, 10:12 AM] mbbs 2016 UG1: I couldn't find an answer to it.
[5/23, 10:13 AM] PG Post Residency 1 : Good. Then let us start the active learning around this question. First let me share some discussion with another student below
"Good morning sir!
Sir, why was there no biopsy taken from the abscess sites? To check for what bacteria might've caused it?"
" Because I'm not able to visualize being able diagnose tuberculosis with the given data."
" Check out the MRI report"
" Sir. Isn't there also a possibility that during the I&D for gluteal abscess there was damage to L4 and 5 which lead to the paraparesis?"
" Very Good question. Ask our interns and PGs. Tell me if you need their numbers"
" Yes sir. Because in a few cases I've read
And most of them also had no AFB"
" How sensitive and specific is that and would it be useful for our patient?"
" Sir. The pus from the pyocele was sent for culture sensitivity and revealed no AFB it seems sir"
" Tuberculous abscesses are only diagnosed on the basis of histo pathology"
" Okay sir. I shall ask her"
" The question is why didn't we send a biopsy of the abscess tract to get a better histopathology diagnosis"
"I have the asked for the report from the intern, and she is yet to reply."
" They also had positive tuberculin Skin test sir"
" It's already there in one of their e logs shared with you"
[5/23, 10:17 AM] mbbs 2016 UG1 : It's not very sensitive because most of us have received a BCG vaccine, which would give us a false positive
[5/23, 10:18 AM] mbbs 2016 UG1: Did we assume he has TB? There seems to be no substantial evidence to prove it.
[5/23, 10:18 AM] PG post residency 1 : Can you share some literature that says BCG vaccination gives false positive Mantoux test.
Also is being Mantoux or tuberculin positive the same as being diseased?
[5/23, 10:30 AM] mbbs 2016 UG1: I found two conflicting studies :
https://pubmed.ncbi.nlm.nih.gov/28087302/?from_single_result=28087302&expanded_search_query=28087302
The above study provides evidence that BCG vaccination after infancy may influence TST results beyond the 10-year period conventionally accepted by the Centers for Disease Control and Prevention (CDC), extending up to 55 years after vaccination. This suggests that BCG vaccination should be taken into account when interpreting TST results regardless of the time elapsed since vaccination.
https://pubmed.ncbi.nlm.nih.gov/17131776/?from_single_result=17131776&expanded_search_query=17131776
Whereas, this study claims that The effect on TST of BCG received in infancy is minimal, especially > or =10 years after vaccination. BCG received after infancy produces more frequent, more persistent and larger TST reactions.
[5/23, 4:14 PM] PG Post Residency 1: 👍👏👏
Ok now let's back to solving the problem of confirming the diagnosis of tuberculosis in the patient. What would have been the best way forward to prove tuberculosis in this patient instead of beginning the treatment empirically?
[5/23, 4:23 PM] mbbs 2016 ug1: CBNAAT
[5/23, 4:28 PM] PG Post residency 1: CBNAAT of what?
[5/23, 4:33 PM] mbbs 2016 ug1: of sputum
[5/23, 4:35 PM] mbbs 2016 ug1: Sputum smear for AFB and Chest X-ray should also be performed
[5/23, 4:50 PM] PG Post residency 1: Wasn't it performed? Please ask the interns and PGs who made the log
[5/23, 4:54 PM] mbbs 2016 ug1: Alright sir.
[5/23, 4:57 PM] mbbs 2016 ug1: And sir, how is this related to Vasculitis?
[5/23, 4:59 PM] PG POST RESIDENCY 1:
Conversation with another student "So is it ACA Vasculitis as mentioned by one of my classmates??"
[5/23, 4:59 PM] PG POST RESIDENCY 1: "I mean is the diagnosis Tubercular ACA vasculitis in the medial Homenculus area of cerebral cortex??"
[5/23, 4:59 PM] PG POST RESIDENCY 1: "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606267/
This link she mentioned also tells about cerebral vasculitis without TBM"
[5/23, 4:59 PM] PG POST RESIDENCY 1: "Yes share the interesting learning points that you gained from that article 👍"
[5/23, 5:01 PM] mbbs 2016 ug1 Thanks Sir!
[5/23, 5:30 PM] mbbs 2016 ug1: Here are a few doubts I have,
[5/23, 5:40 PM] mbbs 2016 ug1: According to the MR images shared, there seems to be no evidence that the region of the cerebral cortex supplied by the ACA is affected to conclude that it is the cause of the paraparesis.
[5/23, 6:24 PM] KIMs 2016 ug1: THE ANATOMICAL LOCATION
of the UMN lesion could be anywhere - Primary Motor Cortex, Internal Capsule, Midbrain, Pons , Lateral Corticospinal Tract
[5/23, 6:29 PM] KIMs 2016 ug1: THE PATHOLOGY
could be -
1. Damage to the brain - due to Thrombus, Hemorrhage (Stroke), Infection, Tumour (Cancer), PML
2. Injury to the brainstem or white matter of the spinal cord - due to Multiple Sclerosis, Transverse Myelitis, Trauma, Spinal Stenosis, Spinal Abscess
[5/23, 6:36 PM] KIMs 2016 ug1: How do we localise the anatomical location affected in this UMN lesion which may have caused the paraparesis? Is the only was to do so by performing an MRI of the brain and the spinal cord? How does one interpret it?
[5/23, 6:43 PM] KIMs 2016 ug1: What is the relationship between the psoas absess and "the ring enhancing lesions seen in the right and left cerebral hemispheres" on MRI?
[5/23, 7:02 PM] KIMs 2016 ug1: Mostly, The vertebral lesion could not be producing any neurological signs because according to the MRI spine report , the patient has L4, L5 Spondylodiscitis which means, most likely, the spinal cord could not have been involved as it ends at the level of L1,L2 vertebrae. Though, the cause of the Psoas Abscess and Gluteal Abscess (Both cold abscesses) can be explained by spread of AFB from the L4,L5 Spondylodiscitis as commonly seen in Tuberculous spondylodiscitis.
[5/23, 7:54 PM] pg post residency 1: 👍Yes the last paragraph is spot on
[5/23, 7:54 PM] pg post residency : The ring enhancing lesions could be tuberculoma and the psoas abscess is also due to mycobacteria
[5/23, 7:55 PM] pg post residency 1: Have you checked the report? The very few films that have been shared may not reveal all
[5/23, 7:59 PM] pg post residency 1: Yes but the first step is to localise it anatomically and the clinical possibilities were bilateral leg area of the brain and high cervical cord. Brain stem was unlikely as there was no cranial nerve involvement.
Once the localization is over then the pathology can range from vascular, demyelinating, degenerative to neoplasia
[5/23, 8:17 PM] KIMs 2016 ug1: I've only seen the images shared on the blog by Vaishnavi ma'am (intern)
[5/23, 8:21 PM] KIMs 2016 ug1: What symptoms or signs may the Tuberculoma be causing?
[5/23, 8:24 PM] pg post residency: Check the report. Or ask Vaishnavi to share the radspa link to the entire mri images with you
[5/23, 8:25 PM] pg post residency1: Good question. Currently none that we know of
[5/23, 8:33 PM] KIMs 2016 ug1: In the Brain, that would be the Precentral Gyrus in the frontal lobe. What points us towards a high cervical cord lesion?
[5/23, 8:34 PM] KIMs 2016 ug1: One possibility could be Vomiting (which was described as non-projectile by the patient but could be projectile in actuality)
[5/23, 8:38 PM] pg post residency 1: UMN signs that are above the C5 cervical cord as biceps C5 is exaggerated.
Above the high cervical cord comes the brain stem which is ruled out as there are no cranial nerve involvement and finally bilateral cortical leg area is the only location left
[5/23, 8:38 PM] pg postresidency 1: Why would the ring enhancing lesions cause vomiting?
[5/23, 8:45 PM] KIMs 2016 ug1: Due to raised ICT
[5/23, 8:47 PM] pg postresidency 1: Do ring enhancing lesions cause raised ICT without any focal neurological deficit?
[5/23, 8:47 PM] KIMs 2016 ug1: Vasculitis of the ACA explains the lesion at the bilateral cortical leg area.
But, what could be the cause for a lesion above the C5 cervical cord?
[5/23, 8:51 PM] pg postresidency 1: When someone has quadriparesis due to an apparent UMN lesion above C5 then the differentials become either high cord lesion or brain stem lesion or cortical or internal capsular lesion
[5/23, 9:45 PM] KIMs 2016 ug1: I still don't understand how he was diagnosed with TB, sir.
[5/23, 10:12 PM] KIMs 2016 ug1: I asked Rashmitha ma'am whether Sputum Smear for AFB and CBNAAT was done and she said that the sputum was not inducible, so it wasn't possible and that the abscess pus was negative.
[5/23, 10:17 PM] pg postresidency 1: 👍
What other disease can produce such pus everywhere and also spread to the brain? (DIFFERENTIAL DIAGNOSIS)
[5/23, 10:19 PM] KIMs 2016 ug1: What about Sarcoidosis?
[5/23, 10:21 PM] Rakesh Biswas: Share a similar case reported with sarcoidosis
[5/24, 3:09 PM] KIMs 2016 ug1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3669974/
[5/24, 3:09 PM] KIMs 2016 ug1: dDx : Spinal Sarcoidosis - Osseous spinal sarcoidosis: an unusual but important entity to remember
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3030116/
[5/24, 3:15 PM] KIMs 2016 ug1: Other questions I had are:
1. What pathology could be responsible for a lesion at or above the C5 cervical cord? Vascular, demyelinating, degenerative, neoplasia? Was anything visible on radiology?
2. How do we rule out various pathologies after we have located the anatomical location of the lesion causing the UMN symptoms (paraparesis)? Which in this case is the bilateral leg area of the brain.
3. Why didn't we do a biopsy for histopathological diagnosis of the affected vertebrae showing spondylodiscitis (L4,L5) on MRI?
Because as I mentioned, any pathogenic organism could have caused it.
4. Why don't ring enhancing lesions cause raised ICT without any neurological deficit?
[5/24, 3:39 PM] pg post residency 1: Did this patient in the report have spinal cord or peripheral nerve involvement due to sarcoid?
[5/24, 3:50 PM] pg post residency 1 : Very good questions.
1) For that particular patient no pathology was visible in any part of the spinal cord although clinically one strong differential was high cervical cord due to the clinical neurological findings of localization.
2. Ultimate diagnosis was always made in the past by biopsy either through autopsy in case of unfortunate death of the patient or through operative biopsy. Because getting those are invasive and difficult the other option in medical decision making is to go by statistical probability of the pathology.
3) As stated above because of high statistical probability of a treatable infectious pathology known to cause similar findings in the past, most physicians avoid invasiveness and favor tolerating moderate diagnostic uncertainty over the ability to provide potential relief through easily available standard course of treatment.
4) If those ring enhancing lesions were tumors or inflammed infective lesions such as neurocysticercosis or tuberculoma (ours was possibly a non inflammed tuberculoma) they can cause raised ICT. Focal deficits are seen in ring enhancing lesions when they impinge on the pyramidal pathway.
I guess our previous discussion around this was incomplete and hence the confusion. Thanks for diligently pursuing it. 👍"
TREATMENT:
Non-Pharmacological:
(Kindly note, the key learning points have been highlighted in ORANGE and GREEN below)
Case 2:
"[5/23, 10:06 AM] mbbs 2016 UG1: Sir, what symptoms made us suspect TB in this case? How did we confirm the diagnosis of TB in this case?
https://vaish7.blogspot.com/2020/05/medicine.html?m=1
[5/23, 10:11 AM] PG Post residency PG1: Go through this active learning discussion and let me know if you still don't have the answer.
https://medicinedepartment.blogspot.com/2020/05/frequently-asked-questions-around-case.html?m=1
Then we can add our active learning discussion to it around this question
[5/23, 10:11 AM] mbbs 2016 UG1: I went through it sir.
[5/23, 10:12 AM] mbbs 2016 UG1: I couldn't find an answer to it.
[5/23, 10:13 AM] PG Post Residency 1 : Good. Then let us start the active learning around this question. First let me share some discussion with another student below
"Good morning sir!
Sir, why was there no biopsy taken from the abscess sites? To check for what bacteria might've caused it?"
" Because I'm not able to visualize being able diagnose tuberculosis with the given data."
" Check out the MRI report"
" Sir. Isn't there also a possibility that during the I&D for gluteal abscess there was damage to L4 and 5 which lead to the paraparesis?"
" Very Good question. Ask our interns and PGs. Tell me if you need their numbers"
" Yes sir. Because in a few cases I've read
And most of them also had no AFB"
" How sensitive and specific is that and would it be useful for our patient?"
" Sir. The pus from the pyocele was sent for culture sensitivity and revealed no AFB it seems sir"
" Tuberculous abscesses are only diagnosed on the basis of histo pathology"
" Okay sir. I shall ask her"
" The question is why didn't we send a biopsy of the abscess tract to get a better histopathology diagnosis"
"I have the asked for the report from the intern, and she is yet to reply."
" They also had positive tuberculin Skin test sir"
" It's already there in one of their e logs shared with you"
[5/23, 10:17 AM] mbbs 2016 UG1 : It's not very sensitive because most of us have received a BCG vaccine, which would give us a false positive
[5/23, 10:18 AM] mbbs 2016 UG1: Did we assume he has TB? There seems to be no substantial evidence to prove it.
[5/23, 10:18 AM] PG post residency 1 : Can you share some literature that says BCG vaccination gives false positive Mantoux test.
Also is being Mantoux or tuberculin positive the same as being diseased?
[5/23, 10:30 AM] mbbs 2016 UG1: I found two conflicting studies :
https://pubmed.ncbi.nlm.nih.gov/28087302/?from_single_result=28087302&expanded_search_query=28087302
The above study provides evidence that BCG vaccination after infancy may influence TST results beyond the 10-year period conventionally accepted by the Centers for Disease Control and Prevention (CDC), extending up to 55 years after vaccination. This suggests that BCG vaccination should be taken into account when interpreting TST results regardless of the time elapsed since vaccination.
https://pubmed.ncbi.nlm.nih.gov/17131776/?from_single_result=17131776&expanded_search_query=17131776
Whereas, this study claims that The effect on TST of BCG received in infancy is minimal, especially > or =10 years after vaccination. BCG received after infancy produces more frequent, more persistent and larger TST reactions.
[5/23, 4:14 PM] PG Post Residency 1: 👍👏👏
Ok now let's back to solving the problem of confirming the diagnosis of tuberculosis in the patient. What would have been the best way forward to prove tuberculosis in this patient instead of beginning the treatment empirically?
[5/23, 4:23 PM] mbbs 2016 ug1: CBNAAT
[5/23, 4:28 PM] PG Post residency 1: CBNAAT of what?
[5/23, 4:33 PM] mbbs 2016 ug1: of sputum
[5/23, 4:35 PM] mbbs 2016 ug1: Sputum smear for AFB and Chest X-ray should also be performed
[5/23, 4:50 PM] PG Post residency 1: Wasn't it performed? Please ask the interns and PGs who made the log
[5/23, 4:54 PM] mbbs 2016 ug1: Alright sir.
[5/23, 4:57 PM] mbbs 2016 ug1: And sir, how is this related to Vasculitis?
[5/23, 4:59 PM] PG POST RESIDENCY 1:
Conversation with another student "So is it ACA Vasculitis as mentioned by one of my classmates??"
[5/23, 4:59 PM] PG POST RESIDENCY 1: "I mean is the diagnosis Tubercular ACA vasculitis in the medial Homenculus area of cerebral cortex??"
[5/23, 4:59 PM] PG POST RESIDENCY 1: "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606267/
This link she mentioned also tells about cerebral vasculitis without TBM"
[5/23, 4:59 PM] PG POST RESIDENCY 1: "Yes share the interesting learning points that you gained from that article 👍"
[5/23, 5:01 PM] mbbs 2016 ug1 Thanks Sir!
[5/23, 5:30 PM] mbbs 2016 ug1: Here are a few doubts I have,
[5/23, 5:40 PM] mbbs 2016 ug1: According to the MR images shared, there seems to be no evidence that the region of the cerebral cortex supplied by the ACA is affected to conclude that it is the cause of the paraparesis.
[5/23, 6:24 PM] KIMs 2016 ug1: THE ANATOMICAL LOCATION
of the UMN lesion could be anywhere - Primary Motor Cortex, Internal Capsule, Midbrain, Pons , Lateral Corticospinal Tract
[5/23, 6:29 PM] KIMs 2016 ug1: THE PATHOLOGY
could be -
1. Damage to the brain - due to Thrombus, Hemorrhage (Stroke), Infection, Tumour (Cancer), PML
2. Injury to the brainstem or white matter of the spinal cord - due to Multiple Sclerosis, Transverse Myelitis, Trauma, Spinal Stenosis, Spinal Abscess
[5/23, 6:36 PM] KIMs 2016 ug1: How do we localise the anatomical location affected in this UMN lesion which may have caused the paraparesis? Is the only was to do so by performing an MRI of the brain and the spinal cord? How does one interpret it?
[5/23, 6:43 PM] KIMs 2016 ug1: What is the relationship between the psoas absess and "the ring enhancing lesions seen in the right and left cerebral hemispheres" on MRI?
[5/23, 7:02 PM] KIMs 2016 ug1: Mostly, The vertebral lesion could not be producing any neurological signs because according to the MRI spine report , the patient has L4, L5 Spondylodiscitis which means, most likely, the spinal cord could not have been involved as it ends at the level of L1,L2 vertebrae. Though, the cause of the Psoas Abscess and Gluteal Abscess (Both cold abscesses) can be explained by spread of AFB from the L4,L5 Spondylodiscitis as commonly seen in Tuberculous spondylodiscitis.
[5/23, 7:54 PM] pg post residency 1: 👍Yes the last paragraph is spot on
[5/23, 7:54 PM] pg post residency : The ring enhancing lesions could be tuberculoma and the psoas abscess is also due to mycobacteria
[5/23, 7:55 PM] pg post residency 1: Have you checked the report? The very few films that have been shared may not reveal all
[5/23, 7:59 PM] pg post residency 1: Yes but the first step is to localise it anatomically and the clinical possibilities were bilateral leg area of the brain and high cervical cord. Brain stem was unlikely as there was no cranial nerve involvement.
Once the localization is over then the pathology can range from vascular, demyelinating, degenerative to neoplasia
[5/23, 8:17 PM] KIMs 2016 ug1: I've only seen the images shared on the blog by Vaishnavi ma'am (intern)
[5/23, 8:21 PM] KIMs 2016 ug1: What symptoms or signs may the Tuberculoma be causing?
[5/23, 8:24 PM] pg post residency: Check the report. Or ask Vaishnavi to share the radspa link to the entire mri images with you
[5/23, 8:25 PM] pg post residency1: Good question. Currently none that we know of
[5/23, 8:33 PM] KIMs 2016 ug1: In the Brain, that would be the Precentral Gyrus in the frontal lobe. What points us towards a high cervical cord lesion?
[5/23, 8:34 PM] KIMs 2016 ug1: One possibility could be Vomiting (which was described as non-projectile by the patient but could be projectile in actuality)
[5/23, 8:38 PM] pg post residency 1: UMN signs that are above the C5 cervical cord as biceps C5 is exaggerated.
Above the high cervical cord comes the brain stem which is ruled out as there are no cranial nerve involvement and finally bilateral cortical leg area is the only location left
[5/23, 8:38 PM] pg postresidency 1: Why would the ring enhancing lesions cause vomiting?
[5/23, 8:45 PM] KIMs 2016 ug1: Due to raised ICT
[5/23, 8:47 PM] pg postresidency 1: Do ring enhancing lesions cause raised ICT without any focal neurological deficit?
[5/23, 8:47 PM] KIMs 2016 ug1: Vasculitis of the ACA explains the lesion at the bilateral cortical leg area.
But, what could be the cause for a lesion above the C5 cervical cord?
[5/23, 8:51 PM] pg postresidency 1: When someone has quadriparesis due to an apparent UMN lesion above C5 then the differentials become either high cord lesion or brain stem lesion or cortical or internal capsular lesion
[5/23, 9:45 PM] KIMs 2016 ug1: I still don't understand how he was diagnosed with TB, sir.
[5/23, 10:12 PM] KIMs 2016 ug1: I asked Rashmitha ma'am whether Sputum Smear for AFB and CBNAAT was done and she said that the sputum was not inducible, so it wasn't possible and that the abscess pus was negative.
[5/23, 10:17 PM] pg postresidency 1: 👍
What other disease can produce such pus everywhere and also spread to the brain? (DIFFERENTIAL DIAGNOSIS)
[5/23, 10:19 PM] KIMs 2016 ug1: What about Sarcoidosis?
[5/23, 10:21 PM] Rakesh Biswas: Share a similar case reported with sarcoidosis
[5/24, 3:09 PM] KIMs 2016 ug1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3669974/
[5/24, 3:09 PM] KIMs 2016 ug1: dDx : Spinal Sarcoidosis - Osseous spinal sarcoidosis: an unusual but important entity to remember
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3030116/
[5/24, 3:15 PM] KIMs 2016 ug1: Other questions I had are:
1. What pathology could be responsible for a lesion at or above the C5 cervical cord? Vascular, demyelinating, degenerative, neoplasia? Was anything visible on radiology?
2. How do we rule out various pathologies after we have located the anatomical location of the lesion causing the UMN symptoms (paraparesis)? Which in this case is the bilateral leg area of the brain.
3. Why didn't we do a biopsy for histopathological diagnosis of the affected vertebrae showing spondylodiscitis (L4,L5) on MRI?
Because as I mentioned, any pathogenic organism could have caused it.
4. Why don't ring enhancing lesions cause raised ICT without any neurological deficit?
[5/24, 3:39 PM] pg post residency 1: Did this patient in the report have spinal cord or peripheral nerve involvement due to sarcoid?
[5/24, 3:50 PM] pg post residency 1 : Very good questions.
1) For that particular patient no pathology was visible in any part of the spinal cord although clinically one strong differential was high cervical cord due to the clinical neurological findings of localization.
2. Ultimate diagnosis was always made in the past by biopsy either through autopsy in case of unfortunate death of the patient or through operative biopsy. Because getting those are invasive and difficult the other option in medical decision making is to go by statistical probability of the pathology.
3) As stated above because of high statistical probability of a treatable infectious pathology known to cause similar findings in the past, most physicians avoid invasiveness and favor tolerating moderate diagnostic uncertainty over the ability to provide potential relief through easily available standard course of treatment.
4) If those ring enhancing lesions were tumors or inflammed infective lesions such as neurocysticercosis or tuberculoma (ours was possibly a non inflammed tuberculoma) they can cause raised ICT. Focal deficits are seen in ring enhancing lesions when they impinge on the pyramidal pathway.
I guess our previous discussion around this was incomplete and hence the confusion. Thanks for diligently pursuing it. 👍"
TREATMENT:
Non-Pharmacological:
- Health Education about Tuberculosis and STIs.
- Use of physical barrier methods of contraception (condoms) to avoid Sexually Transmitted Disease from High Risk Behaviour.
- Rehabilitation through Physiotherapy for Pott's spine.
Pharmacological:
- Anti- Tubercular Therapy (ATT) 3 tablets/day Fixed Dose Combination for 6 months
- T. BENADON 40 MG/OD
- T. PREGABALIN 75 MG/PO/H/S
- OINT. MEGAHEAL FOR LOCAL APPLICATION
- SITZ BATH WITH BETADINE TID
- FREQUENT CHANGE OF POSITION
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