Thursday, January 08, 2015

Short Case with Prof. How

We discussed on two patients today: acute transverse myelitis and unilateral gouty arthritis.

Patient 1 
49-year-old Chinese man presented with bilateral lower limb weakness. On examination, patient was lying supine, and in pain. He had urine catheter. There was fasciculation noted, but no muscle wasting. He had bilateral lower limb hypotonia, power 0/5 and areflexia. Babinski positive. No clonus. Sensation reduced up until T4 level.

Further examination revealed patient had tenderness at his upper back, and left shoulder. Upper limbs had normal tone and power. No facial paralysis or ophthalmoplegia.

1. What are your findings in this patient?

Paraplegia and sensory loss up until T4 level due to Upper Motor Neuron Disease.

2. Is it possible for patients with UMND presented with hypotonia and areflexia?

Yes. This indicates patient is in spinal shock - acute stage.

3. Differential diagnosis for this patient?
  • Autoimmune/Demyelinating : Acute Transverse Myelitis, Guillain Barre Syndrome
  • Tumour : Benign or malignant tumor, Secondary metastasis to bone
  • Infection : TB spine, abscess
  • Ortho : Disc prolapse, Spondylolisthesis
  • Trauma
4. Other causes of paraplegia?
  • Osteoporotic bone fracture, most common in women
  • Meningomyelocele in babies
5. How do you want to investigate this patient?
  • Spinal XRay Lateral and AP view to rule out bone abnormalities such as spondylolisthesis, osteoporotic bone fracture (bone appears dense, reduced intervertebral space, compression fracture), TB spine (destruction of intervertebral disc and vertebral body, reduced intervertebral space, wedge shape) or bone malignancy (loss of pedicle, lytic or sclerotic lesion)
  • CSF analysis to rule out infection
  • MRI of spinal cord
  • Blood tests to rule out SLE, HIV 
6. Causes of acute transverse myelitis?

It can be divided into primary and secondary causes. 
Primary is idopathic. Secondary can be due to:
  • Infections : Viral (Herpes, West Nile), Bacteria (Borrelia Burgdorferi in Lyme disease) or rarely parasites
  • Multiple Sclerosis
  • Neuromyelitis Optica (Devic's disease)
  • Autoimmune : SLE, Sjogren's syndrome
  • Vaccinations for infectious diseases : Hepatitis B, MMR, DPT
7. How do you manage patients with acute transverse myelitis?

Give high dose intravenous methylprednisolone to hasten recovery process, duration for about 5 days. If patient does not respond, do plasmapheresis to remove the antibodies involved in inflammation. Give painkillers. Do physiotherapy to improve muscle strength, coordination and range of motion. Occupational therapy and psychotherapy can help. 

8. If a young lady came to you with paraplegia with history of unilateral blurring of vision, what should you think of?

MULTIPLE SCLEROSIS! Because, MS is a relapsing and remitting disease. It is most common in female of 20-40 years old. Patient usually comes with episodes focal disorder of optic nerves (blindness), spinal cord (weakness, numbness) or brainstem (internuclear ophthalmoplegia, cerebellar ataxia). 

Multiple Sclerosis
Source : X'Press Revision in Short Cases by UM Press

How to examine patient with myelopathy
Source : X'Press Revision in Short Cases by UM Press

Patient 2
An elderly man presented with right knee joint swelling. On examination, right knee joint was not erythematous, no surgical scar seen. It was non-tender. He had right knee joint effusion. Further examination was not done due to patient's condition.

1. What are the differential diagnosis?

Septic arthritis, gouty arthritis, rheumatoid arthritis, pseudogout, haemarthrosis.

2. What are the differences between gout and pseudogout?

Gout is caused by deposition of monosodium urate crystals in and near joints. Pseudogout is due to deposition of calcium pyrophosphate dehydrate.

3. Causes of gout?

It can be divided into primary and secondary. 
Primary is idiopathic hyperuricaemia or G6PD. Secondary causes:
  • Overproduction of uric acid : Hemolysis, Lymphoproliferative diseases, Myeloproliferative diseases, Polycytemia vera, Psoriasis, Paget's disease, Rhabdomyolysis, Obesity, Purine-rich diet
  • Decrease excretion of uric acid : Renal insufficiency, Diabetes insipidus, Hypertension, Sarcoidosis, Hyperparathyroidism, Hypothyroidism, Drugs (diuretics, levodopa, cyclosporine, salicylates, ethambutol, pyrazinamide)
  • Alcohol and Shock 
4. Investigations for this patient?

  • Joint fluid aspiration - check for monosodium urate crystals 
  • Because patients with gout often have other diseases like metabolic syndrome, kidney stones and ischaemic heart disease, so we do baseline tests such as FBC, Urinalysis, Creatinine, BUSE, Serum uric acid, ECG 
  • Knee joint XRay

Imaging in OA, RA and gout

That's all for short cases. Goodnight! :)

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