grand round 1

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GROUND ROUND PRESENTATION

• PRESENTERSLIGHTNESS KIMAMBO,DAVID KIZENGA,
  IRENE KIMARO,NAILA KHIMJI,ASHNA KHALIL,
• FACILITATORS DR JOYCE SABUKA DR WENSESLAUS MARO

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PATIENT PARTICULARS

• NAME F.J.C
• SEX FEMALE
• AGE 23 YEARS
• ADDRESS MBEZI BEACH
• TRIBE LUGURU
• OCCUPATION STUDENT
• RELIGION CHRISTIAN
• MARITAL STATUS SINGLE
• EDUCATION LEVEL O-LEVEL
• INFORMANT PATIENT
• NEXT OF KIN MOTHER
• DATE OF ADMISSION 01/01/2024
• DATE OF CLERKSHIP 02/01/2024
• NUMBER OF HOSPITAL STAY 1 DAY
• REFFERAL SELF REFERRAL

3
CHIEF COMPLAINT

• Lower Limb Weakness for 7 days

4
HISTORY OF PRESENTING ILLNESS

• The patient present with gradual onset of
• lower limb weakness for 7 day which was
  progressing.
• 1 day prior to onset of symptoms she reported
• to have long walk and climbing mountain at
  Morogoro.
• Initially she could walk with support and
• on the next day she was unable to walk even with
  support.
• She could use her upper limbs normally and
• no noticeable changes reported.
• It was associated with numbness and tingling
  sensation
• with inability to control urine and stool.
• She reports no blood in stool and urine, no flank
  pain, no diarrhea

5
CONT

• She massaged herself with warm water,
• which made her sustain blisters and wounds at
  lower limbs.
• However the patient denied h/o
• headache, dizziness, blurry vision, convulsions,
• tremors, muscle pain, joint pain / swelling, loss
  of consciousness,
• No h/o
• recent Trauma/ lifting heavy object
• Open Tb contact , drenching night sweats,
  significant weight loss

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REVIEW OF OTHER SYSTEMS

• EENT (EARS, EYES, NOSE AND THROAT)
• No history of ear pain , discharge or hearing
  loss
• No history of eye pain, discharge or loss of eye
  sight
• No history of nasal pain, discharge or bleeding,
  no loss of smell
• No history of throat pain or painful swallowing
• CARDIOVASCULAR SYSTEM
• No hx of central chest pain
• No hx of difficulty in breathing on lying flat
• No hx of awareness of heartbeats
• No hx of lower limb swelling

7
CONT

• RESPIRATORY SYSTEM
• No hx of chest pain
• No hx of difficulty in breathing
• No hx of cough
• No coughing up blood
• No hx of wheezing

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CONT

• ENDOCRINE SYSTEM
• No excessive thirst 
• No heat intolerance 
• No cold intolerance
• No excessive urination
• INTEGUMENTARY SYSTEM 
• No itchy skin
• No skin discoloration
• No skin lesion.

9
PAST MEDICAL HISTORY.

• This is her first admission.
• Patient has had previous two OPD visits in a
  dispensary in Kawe for back pain.
• The first visit was in September 2023 and she was
  diagnosed with UTI and treated by medication.
• The second visit was in December where she was
  given tramadol to relieve the pain.
• She has no history of any other chronic illness
  like HTN, DM, SCD.
• She has no history of surgery and blood
  transfusion.
• Patient has no history of long-term medication
• No hx of food/drug allergy.
• No hx of using herbal medication

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GYNECOLOGICAL HISTORY

• Attained menarche at 16years
• Has regular cycle of 30 days and her periods last
  for 3 to 4 days
• She uses approximately three pads per day which
  are not fully soaked with blood.
• No severe pain during menstruation
• Last normal menstrual period was on 23rd December
  2023
• No hx of contraceptive use

11
FAMILY HISTORY

• 2ND born out of 5 children
• All her siblings are well and alive.
• Both her parents are well and alive
• No history of familial illness (DM, HTN, SICKLE
  CELL, HAEMOPHILIA) in maternal/paternal side.
• No history of sudden death in the family.

12
SOCIAL HISTORY

• She is single, has no children and is not
  sexually active.
• She has no history of alcohol intake
• No history of smoking.
• She lives in a well ventilated house and sleeps
  under a mosquito net.
• She does not do physical exercise.

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DIETARY HISTORY

• She takes 3 meals per day,
• In the morning she takes Bread and Tea,
• In the afternoon she takes Ugali and meat with
  vegetables.
• At night she takes rice and beans with fruits.
• She also takes about 1 litre of water per day.

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SUMMARY 1

• F.J.C, a 23 year old female student who presented
  with lower limbs weakness for 7 days which was
  progressive in nature associated with numbness
  and tingling sensation, dual incontinence.
• No hx of headache, convulsion, loss of
  consciousness or fever.
• Hx of back pain 3 months prior
• No hx of trauma, weigh tloss , drenching night
  sweats or open tb contact

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CLINICAL DIAGNOSIS BASED ON HX

• Paraplegia secondary to Transverse Myelitis
• Point for
• Acute onset of Paraplegia,
• Age young 23 y/o,
• Numbness and tingling sensation,
• Urine and fecal incontinence
• Differential diagnosis based on history
• Potts disease
• Point for
• progressive in nature, paraplegia, h/o back pain
• Point against
• no h/o productive cough, night sweats, no fever,
  no significant weight loss

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Cont..

• Spine tumors
• Point for paraplegia, h/o back pain
• Point against acute progression, weight loss,

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PHYSICAL EXAMINATION

• GENERAL EXAMINATION
• conscious ,
• with a green cannula on her right cubital fossa
  for iv medications
• urinary catheter with a urine output of 100mls
• She had
• Evenly distributed black colored hair, which were
  not easily pluckable.
• Was pale , not jaundiced and not cyanosed
• Dry mucous membranes, no sunken eyes
• Has normal ears with no discharges.
• No nasal blockage, no nasal discharge.
• No angular cheilitis, normal dental formula,
• no atrophic glossitis and no oral thrush

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Cont..

• No finger clubbing, no koilonychia, no
  Leukonychia,
• no splinter hemorrhage, Normal capillary refill
  of less than 2 seconds,
• no palmar erythema, no Oslers nodes, no Janeway
  lesions ,
• no peripheral lymphadenopathy
• Has no lower limb oedema with blisters and
  dressed wounds discharging sero sanguinous
• VITALS
• BP 114/60mmhg
• Pr 98b/m
• RR 19C/M
• TEMP 38.4C
• SPO298 IN RA
• CONCLUSION PATIENT WAS FEBRILE

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NERVOUS SYSTEM

• Higher center
• The patient had good behavior and attitude
• towards answering questions.
• The patient had good memory could recall
• the asked listed objects asked- short term
• could name the first president of Tanganyika-long
  term
• she had normal speech.
• The patient was conscious, well alert and
  oriented to person, place and time with a Glasgow
  Coma scale of 15

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CRANIAL NERVE EXAMINATION

• CN I. OLFACTORY
• The patient could smell soap with each nostril
  at a time with the eyes closed.
• CN II. OPTIC
• Visual Acuity The patient was able to see near
  and distant objects with both right and left
  eyes.
• Visual Field The patient was able to see both of
  my fingers at the same time while looking at my
  eyes with either eye closed.
• Pupil size and shape were bilaterally
  normal,Pupillary constriction to light It was
  positive
• CN III, IV VI. OCCULOMOTOR, TROCHLEAR
  ABDUCENS Movements of eyes in all direction was
  normal
• CN V. TRIGEMINAL Motor root The patient could
  clench the teeth
• Sensory roots the patient responded to light
  touch on ophthalmic, maxillary and mandibular
  areas

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CONT

• CN VII. FACIAL
• The patient could wrinkle the forehead, raise
  eyebrows, show teeth, blow both cheeks, and
  whistle.
• The patient can shut both eyes strongly enough to
  resist opening.
• Sensory The patient was able to detect sweet,
  salt, sour bitter when tested with sugar and
  salt.
• CN VIII. VESTIBULOCOCHLEAR
• The patient could hear the sound from 2 feet away
  from both right and left ears.
• Balance Could not been done as the patient was
  unable to walk.
• Rinne's test Air conduction was better than bone
  conduction in both right and left ears.
• Weber test Was positive.
• CN IX. CN X GLOSSOPHARYNGEAL VAGUS
• Both sides of the palate move fully and
  symmetrically

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CONT

• CN XI ACCESSORY
• Could turn her neck sideways against resistance.
• The patient could shrug her shoulder against
  resistance.
• CN XII HYPOGLOSSAL
• The patient could protrude his tongue and move it
  side to side.
• No deviations or tremors were present

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MOTOR COMPONENT
  R. U. L L. UL R. LL L. LL
Bulk NORMAL NORMAL NORMAL NORMAL
Involuntary movement NIL NIL Nil NIL
Gait - - NOT ASSESED NOT ASSESED
Tone NORMAL NORMAL LOW LOW
Power 5/5 5/5 0/5 0/5
         
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REFLEXES
DEEP TENDON REFLEX RIGHT SIDE LEFT SIDE

BICEPS NORMAL NORMAL
TRICEPS NORMAL NORMAL
PATELLA REDUCED REDUCED
ACHILLES DECREASED DECREASED
BABINSKI NO RESPONSE NO RESPONSE
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SENSORY EXAMINATIONLOSS OF SENSATION FROM LEVEL
OF UMBILICUS BILATERALLY.
Rt UL LT UL RT LL LT LL
PRESSURE NORMAL NORMAL NO- NO
VIBRATION NORMAL NORMAL NO NO
FINE TOUCH NORMAL NORMAL NO NO
CRUDE TOUCH NORMAL NORMAL N0 NO
TEMPERATURE NORMAL NORMAL NO NO
PAIN NORMAL NORMAL NO N0
PROPRIOCEPTION NORMAL NORMAL NO NO
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RESPIRATORY SYSTEM

• On inspection Symmetrical chest in morphology.
• There was no any therapeutic or surgical scars.
• The chest movement was symmetrical with a
  respiratory rate of 19 breaths per minute.
• There was no use of accessory muscles in
  breathing.
• On palpation
• No palpable supra clavicular and axillary lymph
  nodes.
• Both breasts was palpable and normal in all
  quadrants.
• The trachea was placed in the midline and the
• cardiac apex beat was felt at the left 5th
  intercostal space, anterior axillary line.
• There was normal tactile vocal fremitus
• Symmetrical chest expansion on both sides of the
  lungs.

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CONT

• On percussion
• Both the lung fields were resonant on
  percussion.
• On auscultation
• Normal vesicular breath sounds were heard
• The vocal resonance was equal on both the sides.

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CARDIOVASCULAR SYSTEM

• The radial pulse was 98 beats/minute,
• Regular regular with normal character
• synchronous with the contralateral pulses.
• Blood pressure of 114/60mmhg at supine lying
  position
• heard at 1st and 5th Korotkoff phase.
• There is no raised jugular venous pressure.
• Negative abdominal jugular reflux

29
Cont

• On precordial exam
• On inspection
• No therapeutic or surgical scars, no precordial
  bulging or precordial hyperactivity.
• On palpation
• cardiac apex beat felt at the left 5th
  intercostal space, anterior axillary line,
• with no heaves no palpable thrills.
• On percussion
• There was dull note heard over the area of the
  heart extended
• from left mid axillary to the mid sternal
  border.
• On auscultation
• Normal S1 and S2 were heard.
• There was no any added sounds, no other sounds
  and no extra sounds were heard.
• No any basal crackles were heard at the bases of
  the lungs.
• No palpable tender liver.

30
GASTRO INTESTINAL SYSTEM

• Oral examination
• Normal dentition, no angular stomatitis, no
  angular chelitis.
• Per abdomen.
• On inspection
• There was normal abdominal contour and
  symmetrical move with respiration.
• Normally inverted umbilicus.
• There was no any surgical or therapeutic scars
  on the abdominal.
• There was no any distended veins

31
Cont

• On palpation
• Negative pointing sign.
• There was no tenderness or any palpable mass
  during superficial and deep palpation.
• Spleen, liver, left and right kidneys were not
  palpable.
• Liver span 12cm
• On percussion
• There was a tympanic note heard on the abdomen.
• No shifting dullness.
• On auscultation
• 3 bowel sounds per minute were heard.
• There were no any vascular bruits heard

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CONT

• DIGITAL RECTAL EXAMINATION
• INSPECTION Normal anal verge with no fissure,
  hemorrhoid, skin erythema and tags seen
• PALPATION reduced anal tone ,free smooth anal
  mucosa with no nodule/swelling with gloved finger
  not stained with feaces and blood
• PER VAGINAL EXAMINATION
• INSPENCTION No abnormal Per vaginal discharge,
  no warts, normal perineum
• PALPATION no mass seen, cervix is closed

33
Summary 2

• F.J.C, a 23 year old female student who presented
  with lower limbs weakness for 7 days ,
  progressive in nature A/w numbness and tingling
  sensation, dual incontinence.
• H/O of back pain 3 months prior
• No hx of headache, convulsion, loss of
  consciousness or fever
• No hx of trauma, weight loss , drenching night
  sweats or open tb contact
• O/E of Patient was febrile (38.4C),pale with
  blisters and dressed wounds discharging sero
  sanguonous on both limbs, hypotonic , No muscle
  contraction seen 0/5,hyporeflexia,negative
  Babinski and loss of sensation from T10.

34
DIAGNOSIS BASED ON HX AND EXAMINATION

• 1. Paraplegia from T10 secondary to Transverse
  Myelitis
• Point for Acute onset of Paraplegia, Age young
  23 y/o, Numbness and tingling sensation, Urine
  and fecal incontinence
• with hypotonia , No muscle contraction seen
  0/5,hyporeflexia,negative Babinski and loss of
  sensation from T10.
• Differential diagnosis based on history and
  examination
• Potts disease
• Point for progressive in nature, paraplegia, h/o
  back pain
• Point against no h/o productive cough, night
  sweats, no fever, no significant weight loss

35
Cont..

• Autoimmune disorders to r/o multiple sclerosis,
  GBS -gullian barren syndrome, SLE
• Reason for sudden progressive onset of
  paraplegia, young age- 23 years, loss of pain,
  pressure and touch sensation., progress in days
  to weeks from onset of symptoms, h/o UTI and
  back pain 3 months ago.
• Reason against patient does not have DIB
• Inflammatory disorders- Malignancies- spinal cord
  metastasis
• Reason forparaplegia, h/o back pain
• Reason against acute progression, no weight loss
• 2. superficial burn injury of the lower limb
  grade 1
• Reason blisters and wounds following massaging
  with warm water, fever

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MANAGEMENT

• Investigation that was supposed to be done
• Baseline investigation
• FBP
• ESR
• CRP
• LFT
• RFT
• Pus swab culture and sensitivity
• Provided initiative treatment and councelling.
• TUMOUR MARKERS
• CARCINONO EMBRYONIC ANTIGEN ,CANCER ANTIGEN 125,
• ALFA FETO PROTEIN ,HUMAN CHORIONIC GONADOTROPHIN
• LACTATE DEHYDROGENASE

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Investigations to be done

• Specific Investigations.
• MRI TOTAL SPINE WITH CONTRAST
• CSF ANALYSIS

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TREATMENT DONE IN WARD

• IV AMOXYCLAV 1.2MG BD FOR 2/7
• METRONIDAZOLE INJ 500MG TDS 5/7
• IV PARACETAMOL 1GM TDS FOR3/7
• TIZANIDINE HYDROCHLORIDE(MUSCLE RELAXANTS) 4MG BD
  FOR 3/7
• SILVER SULFADIAZINE CREAM 10MG APPLY BD FOR 2/52
• To do a wound dressing

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DISCUSSION

• PARAPLEGIA

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PARAPLEGIA

• Paraplegia means paralysis of the legs.
• It is caused mainly by disorders of
• the spinal cord and the cauda equina.
• They are classified as traumatic and non
  traumatic.
• Traumatic paraplegia occurs mostly as a result of
  
• road traffic accidents and falls
• Non traumatic paraplegia (NTP) has multiple
  causes
• most common cause of adult neurological hospital
  admissions in Africa
• after stroke and infection

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NON TRAUMATIC PARAPLEGIA
50

• Common causes of paraplegia in Africa
• Potts disease (TB)
• Inflammation (transverse myelitis)
• Malignancy (metastases)
• Infection (HIV)
• Nutritional (konzo)

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LOCALIZATION OF THE SPINE

• The spinal cord extends from C1 in the neck
• to the lower border of L1
• The cauda equina extends from the end of the cord
• down to S5 within the sacral canal.
• Paraplegia arises from disorders affecting
• the thoracic spinal cord and the cauda equina,
  whereas
• quadriplegia or quadriparesis arises from
  disorders affecting
• the cervical cord
• disorders of the spinal cord result in a spastic
  Paraplegia
• While disorders of the cauda equina result in a
  flaccid Paraplegia

52
COMPRESSIVE CAUSES

• Classified as being either extradural or subdural
  in site
• on neuroimaging (CT/MRI)
• Subdural includes those arising from
• either within the spinal cord (intramedullary)
• or those arising outside the cord
  (extramedullary)
• Main compressive causes in Africa are
• Potts disease and metastatic malignancy,
• both of which are extradural.

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POTTS DISEASE

• Paraplegia arise from direct Tb infection of
  spinal cord or meninges
• The most common cause in
• childhood, adolescence and in young adults.
• Haematogenous spread of the tubercle bacillus
• from pulmonary infection.
• The paraplegia occurs either at the time of the
  primary infection
• or more commonly 3-5 years later by reactivation.
  
• Affecting the intervertebral disc space and
  adjacent vertebrae

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Clinical features of Potts disease

• History of localised back pain, over weeks or
  months,
• worse by weight bearing and followed by a slowly
  progressive paraplegia.
• Uncommonly accompanied by fever, sweating and
  weight loss
• The lower thoracic and the lumbar spine are
  commonly affected.
• Local tenderness and the presence of any
  deformity,
• particular a gibbus formation
• caused by collapse and anterior wedging of
  adjacent vertebrae.

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• Laboratory findings of Potts disease includes
• high ESR with typical spinal x-ray changes
• a characteristic loss of the disc space at the
  site of infection with destruction
• and eventually wedging of adjacent vertebrae
• paravertebral soft tissue swelling
• A CT scan of the spine may also be helpful,
• in early disease when plain X-rays may be normal.
  
• Chest X-ray to exclude active pulmonary
  tuberculosis.
• a needle biopsy
• confirming the presence of acid fast bacilli
• this is diagnostic.

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• The standard antiTB treatment for spinal TB
• is for a total of 18 months, however a shorter 12
  month course has been recently recommended. STG
• Surgical intervention
• decompression of the cord and stabilization of
  the spine
• Prognosis with treatment mortality rate is
  between 10-20
• and full recovery rates of from 25 to 40.

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SPINAL CORD TUBERCULOSIS

• Direct infection of the spinal cord with TB
• presents clinically
• either as an acute myelitis developing over days
• or as a chronic radiculo-myelitis occurring over
  weeks to months.
• The paraplegia is mostly lower motor neurone
• or flaccid in type with absent or depressed
  reflexes
• with urinary and faecal incontinence.
• Tuberculoma of the cord TB meningitis may also
  arise from a source of infection within the
  spinal cord
• screened for HIV infection in all pt with
  paraplegia

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TUMOURS

• Primary spinal cord tumours are very uncommon,
• arising from the cord, roots or meninges,
  affecting all age groups
• evolving more slowly over months or years
• Metastatic malignancy most common cause of
  Paraplegia in the elderly(gt50 years)
• developing over a short period, usually days or
  weeks
• prostate and breast are the most common primary
  sources
• others are lung, kidney, lymphoma and multiple
  myeloma
• They are mostly located extradurally
• commonly affected the thoracic followed by the
  lumbar spine.
• paralysis is usually painful flaccid with a
  sensory level on the trunk

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• DIAGNOSIS
• suspicion of a malignancy with plain spinal
  x-rays
• showing lytic or blastic lesions or vertebral
  collapse
• CSF may sometimes show a high protein level and
  yellow discolouration
• Neuroimaging (CT/MRI) of the spinal cord
• Treatment includes steroids, analgesia,
  radiotherapy chemotherapy
• The prognosis for metastatic spinal cord tumour
  is generally poor

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ACUTE EPIDURAL ABSCESS

• Medical emergency which requires urgent treatment
  
• subacute painful paraplegia occurring over hours
  or days
• Occur in debilitated patients with diabetes,
  alcoholism or renal failure
• even healthy person.
• can also affect all age groups.
• Staphylococcus aureus being the most common
  organism
• skin abscesses and boils are sources of
  infection.
• Presents with very severe pain, sometimes
  radicular,
• and local tenderness at the site of the epidural
  abscess
• /-fever and signs of infection with or without
  meningism.

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• INVESTIGATIONS
• elevated WBC (neutrophil count) and ESR
• CSF examination may reveal the presence of a few
  white blood cells
• and elevated protein level or be normal.
• Lumbar puncture should not be performed near the
  suspected abscess site
• Avoid spread the infection to the CSF and causing
  meningitis.
• Diagnosis is confirmed
• by contrast enhanced CT/MRI spinal cord show
  epidural enhancement
• Treatment is i/v antibiotics (include
  cloxacillin) up to 6 weeks
• High dose intravenous steroids during the first
  week or two
• sometimes surgery decompressive laminectomy may
  be indicated

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NON COMPRESSIVE CAUSES OF PARAPLEGIA

• Transverse myelitis,
• HIV,
• TB,
• schistosomiasis,
• syphilis,
• B-12 deficiency
• and HTLV-1( HUMAN T CELL LYMPHOTROPIC VIRUS TYPE
  1)

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TRANSVERSE MYELITIS

• Affects mainly young middle aged persons
• Episode of inflammation affecting the spinal cord
  
• which results in an acute paraplegia
• It is considered to be infectious and autoimmune
  in origin,
• Also viruses are identified -herpes zoster,
  herpes simplex, HIV and HTLV-1
• But mostly unknown cause
• Paraplegia occurs over hours or days
• with initial flaccidity, sensory level bladder
  and bowel incontinence

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• CSF may show elevation in leucocytes and protein
• MRI/CT scan of the spinal cord useful to exclude
  other causes
• Treatment antiviral medication iv steroids
• Acyclovir 10 mg/kg (800 mg) iv/po/3-4 times daily
  for 10 days
• High dose steroids
• methylprednisolone 1000 mg iv daily for 5 days
• followed by oral prednisolone 60 mg daily,
  tapering over 2-3 weeks.
• High dose dexamethasone, 24-32 mg daily can also
  be used
• if methylprednisolone is unavailable.

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HIV

• Paraplegia is a major but uncommon neurological
  complication in HIV
• main mechanisms are opportunistic infection
  direct HIV infection of the cord
• Includes TB, viral infections syphilis
• vacuolar myelopathy arises from advance HIV
  infection of cord
• causes paraplegia in lt1 of pts
• Management is by treating the underlying cause
  by starting ART

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KONZO

• Konzo is a distinct form of tropical
  myeloneuropathy
• group of paraplegias and peripheral neuropathies
• nutritional in origin
• characterized by abrupt onset of a non
  progressive
• but permanent spastic paraplegia related to
  cassava consumption.
• In epidemics as many as 1-30/1000 persons are
  affected
• mainly growing children and fertile women
• abrupt onset in lt 1 week
• The cause of konzo has been attributed to the
  combined effect of months
• of high cyanide and low protein (methionine and
  cysteine, sulphur based amino acids) intake
• from exclusive consumption of insufficiently
  processed bitter cassava
• Instead of safe processing
• hydrolysis or soaking in water, crushing and
  fermentation or sun drying which takes weeks

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• Supportive investigations
• include elevated blood or urine thiocyanate
  levels
• and low levels of the essential amino acids
  methionine and cysteine.
• Treatment and prevention
• There is no medical treatment
• Prevention is mainly directed at growing cassava
• with lower cyanide content
• and public education concerning safer methods of
  cassava processing.

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REFERENCE

• Neurology in africa by Dr William P. Howlett

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