Case Vignettes in Neurology

PATIENT CASE STUDIES

Case 2 2/17 The neurological evaluation
Case discussion This is a 37 yr old male, amphetamine and cocaine user, admitted 10/26/98 with cough, fever, productive yellow sputum started on antibiotics who after admission gave a 2-4 day history of tingling of the leg, thigh and abdomen right side with progressive weakness left lower leg, and progressive inability to pass urine for 4 days. He required an indwelling foley catheter. On examination the BP was 130/80, pulse rate 90/min and T 38 C. He was unkempt; there were crackles at the right lung base and the back was tender to percussion. He had decreased power 4/5 left hip extension, flexion, knee flexion and extension, left ankle flexion and extension, left leg adduction. Power on the right side was normal. The deep tendon reflexes were present with a decreased ankle reflex on right. Plantar reflex was extensor on the left and flexor on the right. There was decreased pinprick in the right lower leg. There was sensory loss also on the trunk with a T3 level posteriorly on the right ; There was decreased vibration sense in the left lower leg. Perineal sensation was normal and rectal tone was normal.
Summarize the Case in 1-2 sentences. A 37 year-old male amphetamine and cocaine user with lower respiratory infection, and a 2 to 4 day progressive course of right-sided paresthesias, decreased pinprick from T3 down, and reduced DTRs, along with left-sided lower extremity weakness, decreased vibration, and upgoing toes. Also complains of inability to pass urine for 4 days which required foley catheterization. on the long side; this is a 37 yr-old male, amphetamine and cocaine user with pneumonia, and a few days of back pain, progressive R sensory loss and left sided weakness, decreased vibration, extensor plantar reflexes and urinary retention. Discuss lesion localization on the basis of the physical examination. Unilateral (partial) left spinal cord lesion at T1-2 level. good Discuss underlying pathogenesis on the basis of clinical course. The course is subacute, implying and inflammatory process, infection, or mass lesion. good Indicate one likely clinical diagnosis. List (or classify) alternative diagnoses. Brown-Sequard syndrome unilateral cord compression or hemisection, likely due to an extradural abscess complicating the pneumonia. Since unilateral cord lesions usually don't cause bladder problems, the urinary retention is likely hysterical. the clinical diagnosis for this patient was that the urinary retention was hysterical and the patient was sent home with an indwelling catheter; this was an error as the patient actually had a flaccid neurogenic bladder secondary to a acute cord lesion. this is a situation similar to flaccid paralysis occurring acutely after a spinal cord transection. Note that while a flaccid neurogenic bladder often is the consequence of a cauda equina/conus medullaris lower motor neuron syndrome, it can occur acutely with a cord lesion. Furthermore a flaccid neurogenic bladder may be the sole manifestation of an acute cord lesion in the cervical or thoracic region. Indicate 2 ancillary tests that would assist in confirming or refuting the clinical diagnosis. Indicate the test results that would confirm the clinical diagnosis. MRI scan near T1-T2 vertebral level--presence of mass lesion compressing spinal cord Lumbar puncture for evidence of CNS infection--increased white cell count, positive culture mri imaging should be done of the whole spine above the upper thoracic level; for that matter it should probably also be done for the whole spine including the lumbosacral level, because of the possibility of multiple lesions i.e. a LMN at the cauda equina an UMN in the cervical region. note the lesion could be several segments above the clinical sensory level because of the topology of the homonculus in the corticospinal and spinothalamic tracts (legs on the outside, arms on the inside) Indicate complications of the disease and ancillary tests that would help evaluate them. permanent neurological deficit due to cord compression spread of infection to meninges, spinal cord, also neurogenic bladder, septicemia, septic shock Discuss how the underlying pathophysiology is relevant in the management of this patient. Since this is likely an infectious process, antibiotics specific to the infectious organism should be started as soon as possible. Surgical drainage of the abscess may be necessary to decompress the spinal cord. What is the pathophysiological basis for complications of infections of the cns? you need to read up on this. you get an inflammatory process involving blood vessels i.e. a vasculitis that leads to occlusions and infarcts; along with this there is a breakdown of the BBB with potential for further ischemia but also marked vasogenic edema, a hallmark of abscesses in brain or epidurally. in brain the edema icontributes to the mass effect and the rapid deteriorating course; in both locations the breakdown of BBB allows dx with contrast enhancement on imaging studies.

Case 2 2/17 The neurological evaluation

Case discussion

This is a 37 yr old male, amphetamine and cocaine user, admitted 10/26/98 with cough, fever, productive yellow sputum started on antibiotics who after admission gave a 2-4 day history of tingling of the leg, thigh and abdomen right side with progressive weakness left lower leg, and progressive inability to pass urine for 4 days. He required an indwelling foley catheter.

On examination the BP was 130/80, pulse rate 90/min and T 38 C. He was unkempt; there were crackles at the right lung base and the back was tender to percussion. He had decreased power 4/5 left hip extension, flexion, knee flexion and extension, left ankle flexion and extension, left leg adduction. Power on the right side was normal. The deep tendon reflexes were present with a decreased ankle reflex on right. Plantar reflex was extensor on the left and flexor on the right. There was decreased pinprick in the right lower leg. There was sensory loss also on the trunk with a T3 level posteriorly on the right ; There was decreased vibration sense in the left lower leg. Perineal sensation was normal and rectal tone was normal.

Summarize the Case in 1-2 sentences.

A 37 year-old male amphetamine and cocaine user with lower respiratory infection, and a 2 to 4 day progressive course of right-sided paresthesias, decreased pinprick from T3 down, and reduced DTRs, along with left-sided lower extremity weakness, decreased vibration, and upgoing toes. Also complains of inability to pass urine for 4 days which required foley catheterization.

on the long side; this is a 37 yr-old male, amphetamine and cocaine user with pneumonia, and a few days of back pain, progressive R sensory loss and left sided weakness, decreased vibration, extensor plantar reflexes and urinary retention.

Discuss lesion localization on the basis of the physical examination.

Unilateral (partial) left spinal cord lesion at T1-2 level.

good

Discuss underlying pathogenesis on the basis of clinical course.

The course is subacute, implying and inflammatory process, infection, or mass lesion.

good

Indicate one likely clinical diagnosis. List (or classify) alternative diagnoses.

Brown-Sequard syndrome unilateral cord compression or hemisection, likely due to an extradural abscess complicating the pneumonia. Since unilateral cord lesions usually don't cause bladder problems, the urinary retention is likely hysterical.

the clinical diagnosis for this patient was that the urinary retention was hysterical and the patient was sent home with an indwelling catheter; this was an error as the patient actually had a flaccid neurogenic bladder secondary to a acute cord lesion. this is a situation similar to flaccid paralysis occurring acutely after a spinal cord transection. Note that while a flaccid neurogenic bladder often is the consequence of a cauda equina/conus medullaris lower motor neuron syndrome, it can occur acutely with a cord lesion. Furthermore a flaccid neurogenic bladder may be the sole manifestation of an acute cord lesion in the cervical or thoracic region.

Indicate 2 ancillary tests that would assist in confirming or refuting the clinical diagnosis. Indicate the test results that would confirm the clinical diagnosis.

MRI scan near T1-T2 vertebral level--presence of mass lesion compressing spinal cord

Lumbar puncture for evidence of CNS infection--increased white cell count, positive culture

mri imaging should be done of the whole spine above the upper thoracic level; for that matter it should probably also be done for the whole spine including the lumbosacral level, because of the possibility of multiple lesions i.e. a LMN at the cauda equina an UMN in the cervical region. note the lesion could be several segments above the clinical sensory level because of the topology of the homonculus in the corticospinal and spinothalamic tracts (legs on the outside, arms on the inside)

Indicate complications of the disease and ancillary tests that would help evaluate them.

permanent neurological deficit due to cord compression

spread of infection to meninges, spinal cord,

also neurogenic bladder, septicemia, septic shock

Discuss how the underlying pathophysiology is relevant in the management of this patient.

Since this is likely an infectious process, antibiotics specific to the infectious organism should be started as soon as possible. Surgical drainage of the abscess may be necessary to decompress the spinal cord.

What is the pathophysiological basis for complications of infections of the cns? you need to read up on this. you get an inflammatory process involving blood vessels i.e. a vasculitis that leads to occlusions and infarcts; along with this there is a breakdown of the BBB with potential for further ischemia but also marked vasogenic edema, a hallmark of abscesses in brain or epidurally. in brain the edema icontributes to the mass effect and the rapid deteriorating course; in both locations the breakdown of BBB allows dx with contrast enhancement on imaging studies.