return of the trouble

RETURN OF THE TROUBLE-

TUBERCULOUS ARACHNOIDITIS WITH SYRINGOMYELIA-A CASE REPORT

BY-

Akash Srivatsav T

Moderated by-

Dr.N.V.Sundarachary MD;DM

Dr.U.Veramma MD;DM

Dr.R.Lalitha MD.

Name Mr.GCSR

Age 47 years

Sex Male

Marital status Married with a child

Occupation Shopkeeper

Address Guntur

Regd no A030616

DOA 14-07-2014

DOD 21-07-2014

Patient Particulars

Chief symptoms of-

.

• Weakness of both lowerlimbs since six months

• Weakness of both upperlimbs for three months.

• Tingling, numbness and paraesthesias of two months duration.

• Bladder diturbances of two months duration

History Of Present Illness

• Weakness of both the lower limbs in the form

of inability to getup from sitting and

Squatting positions, climbing up-stairs, auto-rikshaw

and bus which was associated with stiffness.

Weakness of both hands while

performing fine finger movements like

mixing food and writing for three

months.

Tingling, numbness and paraesthesias of both

hands and feet for three months which was first

observed in the feet with no subjective loss of

sensations.

Girdle sensation around the upper trunk below

the nipples.

Micturition disturbances like urgency,frequency,overflow incontinence.

Sexual dysfunction in the form of erection and

ejaculation difficulties

No history of

• Speech and language disturbances,

• Disturbances of higher mental functions in any form,

• Cranial nerve involvement in any form,

• Weakness of proximal upperlimb and distal lowerlimb musculature.

No history suggestive of-

• Involvement of cerebellum and meninges,

• Raised IntraCranial Tension,

• Gait disturbances.

Past history

• Diagnosed to have TB meningitis 20 years ago and received ATT for 2 years.

• Underwent lumbar laminectomy 20 years back.

General condition on examination-

Conscious, coherent and oriented.

Moderately built and nourished

No- PallorIcterus

CyanosisClubbingLymphadenopathyPedal oedma

Vitals-

Afebrile

BP-130/80 mm of Hg

PR-78/min

RR-16/min

CNS examination-

Right hand dominant

Speech and language – Normal

Higher mental functions- Normal

Cranial nerves- Normal

Motor examination

Bulk –Normal in all the four limbs

Tone- Spasticity of all the four limbs

Muscle group Right Left

Shoulder 5/5 5/5

Flexion 5/5 5/5

Extension 5/5 5/5

Abduction 5/5 5/5

Adduction 5/5 5/5

Elbow 5/5 5/5

Flexion 5/5 5/5

Extension 5/5 5/5

Wrist 5/5 5/5

Flexion 5/5 5/5

Extension 5/5 5/5

Hand grip 90 % 90 %

Power -

Upper Limbs

Lower limbs

Muscle group Right Left

Hip 4/5 4 /5

Flexion 4/5 4/5

Extension 4/5 4/5

Abduction 4/5 4/5

Adduction 4/5 4/5

Knee 5/5 5/5

Flexion 5/5 5/5

Extension 5/5 5/5

Ankle 5/5 5/5

Dorsi flexion 5/5 5/5

Plantar flexion 5/5 5/5

EHL Normal Normal

EDL Normal Normal

Reflexes

Deep Tendon

Reflexes

Biceps Triceps Supinator Knee Ankle

Right 3 + 3+ 3+ 3 + Absent

Left 3+ 3+ 3+ 3+ Absent

Plantar : Bilateral Equivocal

Superficial reflexes – Present

Sensory Examination

Cutaneous – Pain and Temperature intact

Joint position sense and vibration – Absent in all the four limbs*In upper limbs till the wrist joints*In lower limbs upto the knees

Loss of vibration upto – T4 vertebral level

No meningeal signs

No signs of raised ICT

Provisional Diagnosis

Spastic quadriparesis with peripheral

neuropathy

Differential diagnosis

• Spinal tuberculosis

• Other causes of myelopathy.

INVESTIGATIONS :

Investigation Result

Hb % 10.2gm/dL

RBS 78mg%

ESR 40mm in 1st hr

Blood Urea 14mg%

Serum Creatinine 0.8mg%

Sodium 157mEq/L

Potassium 4.1mEq/L

Chloride 126mEq/L

HIV I Non reactive

HIV II Non reactive

HbsAg Negative

HCV Negative

CSF Analysis

Total Count : 696 cells/cumm

Differential Count : Neutrophils - 80Lymphocytes- 20

Protein : 855 mg/dL

Glucose : 100mg/dL

PANDYS : Positive

ADA – CSF Fluid : 0.9 U/L

PCR for TB antigen : Positive

IMAGING

STUDIES

MRI of whole spine

• Syrinx extending from C3 to D11 with maximum diameter measuring 5.8mm in the dorsal region.

• Status post laminectomy at L4 - L5 level.

• Bilateral facetal hypertrophy at L4 – L5 level.

• Posterior central protrusion at L4 – L5 level causing impingement over the thecalsac with narrowing of bilateral neural foramina causing compression over the exciting nerve roots.

• Crowding of thecal sac at L4 level with increased epidural fat at this level.

• Loculation of CSF opposite from D4 to D6 level on the posterior aspect.

Features represent syrinx with associated sequelae of arachnoiditis.

Nerve conduction studies-

Decreased CMAP amplitudes.

Absent F-waves

Absent SNAPs

Axonal motor sensory polyradiculoneuropathy .

Final diagnosis

Type-III-C Syringomyelia

Extending from C3-D11 with

tuberculous arachnoiditis leading to

Polyradiculoneuropathy.

Treatment• Tab Rifampicin 600mg OD• Tab Isoniazide 450mg OD• Tab Pyrazinamide 750mg BD• Tab Ethambutol 1000mg OD• Tab Prednisolone 1mg/kg body wt in tappering

doses• Tab Tolperisone hydrochloride 150mg OD• Tab Pyridoxine 40mg OD• Tab Calcium OD• Syp Potassium

Outcome

• The patient reported improvement of

I. Tingling, numbness and parasthesias of hands and feet.

II. Weakness of the upper and lower limb musculatures.

III. Micturition disturbances.

DiscussionTuberculosis remains one of the

treatable but troublesome disorders affecting central

nervous system.

A high index of suspicion and detailed evaluation revealed the presence of a coexisting, medically treatable condition in the patient who also had syringomyeliawhich however did not explain his symptomatology.

Also surgery is deferred in our patient.

Conclusion

Tuberculous arachnoiditis resulting in syringomyelia is a

rare and late complication. Our patient has recurrence of

tuberculosis which produced the clinical picture .Indepth

knowledge of the pathophysiology and meticulous workup are

the cornerstones in successful management of such cases .

Bibliography

• Adams and Victor's Principles of Neurology, Ninth Edition

• Bradley's Neurology in Clinical Practice, 6th ed.