A 28 year old male with quadreparesis secondary to infectious spondylitis

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history,  clinical findings, investigations and come up with diagnosis and treatment plan.

 A 28 year old male came with chief complaints of sudden fall followed by weakness of both the lower limbs and loss of hand grip 10 days back, associated with bowel and bladder incontinence.

Patient was apparently asymptomatic 1 month back, following which he developed productive cough, low grade fever for which he underwent sputum studies and tested positive for AFB bacilli and started ATT - HRZE regimen, 2 tab according to weight/PO/OD.

He developed generalized weakness and myalgia 15 days back.

10 days back, patient got up from bed and went to open the door and suddenly fell down, with no loss of consciousness . Following which his brother got him up and since then Patient developed bowel and bladder incontinence.

No h/o sensory impairment.

He is a known case of TB since 1month and on medication  ATT - HRZE

Not a known case of DM,HTN, ASTHMA, EPILEPSY, THYROID DISORDERS, STROKE, CAD.

Personal history:

Diet - mixed

Appetite - normal

Sleep - Adequate

Bowel and bladder incontinence + since 1 week

No allergies 

No addictions

Family history:

His father is a known case of TB and used  ATT for 2 years

On Examination:

Patient is conscious, coherent, co-operative and oriented to time, place and person

No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema.

Temperature - afebrile

PR - 80 BPM

RR - 16 cpm

BP - 100/70 mm Hg

CNS:

Speech - normal

No signs of meningeal irritation

                        Right.           Left

Tone:  UL.         N.                 N

           LL       increased    Increased

Power UL.          4/5.            4/5

             LL.         1/5.           1/5

Cranial.nerves.  : Intact

Sensory system : normal

Reflexes:

                  Right.         Left

Biceps.        3+.             3+

Triceps.       3+.             3+

Supinator.   2+.             2+

Knee.          3+.             3+

Ankle.         3+.              3+

Plantar: extensor

CVS:

S1, S2 heard

No thrills

No Murmurs

Respiratory system:

Trachea - central

BAE +

NVBS heard

No added 

Per abdomen:

Soft, non tender

Bowel sounds - heard

Hernial orifices - normal

No palpable masses

Provisional diagnosis:

Cervical myelopathy?

Potts spine?

Investigations:

Treatment given:

1. Inj. Optineuron 1Amp in 100ml NS  IV/OD

2. Inj. Thiamine 200mg in 100ml NS IV/TID

3. ATT - according to body weight 2 tab PO/OD

4. Bp/ PR/ Spo2/ Temp charting

Update:

FINAL DIAGNOSIS:   Quadreparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 level.

  

                                         

Diagnosis: 

Quadreparesis secondary to infectious spondylitis of C4, C5, C6, C7 and D1 with Epidural abscess at C5 - C6 level.

Treatment given:

Day 1:

1. Inj. Optineuron 1Amp in 100ml NS IV/OD

2. Inj. Thiamine 200mg in 100ml NS IV/TID

3. ATT - according to body weight 2 tab PO/OD

4. Bp/ PR/ Spo2/ Temp charting

Day 2&3:

Same treatment followed.

Day 4:

Inj. Monocef added.

Advice at Discharge:

Referred to Higher center for neurosurgical decompression as MRI showed

1. Infectious spondylitis of C4, C5, C6, C7 and D1 vertebral bodies with significant erosion at C5 - C6 level and the intervening disc space.

2. Epidural abscess at C5 - C6 level measuring 58 x 4 x 18 mm causing cord compression and posterior displacement of the cord.

3. T2/STIR mild cord hyperintensity - suggestive of edema.

4. Prevertebral collection (max AP dimension - 10 mm) extending from C2 to D3 level suggestive of anterior ligamentous spread.

 UPDATE: 

He had surgical drainage of abcess at Osmania and getting discharged tomorrow

Outcome of intervention : 

Patient regained control over bowel and bladder, 

Improvement in power and tone..( as he is walking now) 

Adviced to continue ATT.