Dr. Hill's Spine Case

by

Steven Hill, M.D.

50yo black male with gout, diabetes, and sickle trait in good health and working in construction trades. In retrospect, there was an illness 5-6 weeks ago involving enough vomiting and diarrhea that he missed several days of work.

Oct. 15th he woke unable to move his toes or ankles, with a sensory level at mid shin. He stayed home until Friday Oct. 17th when he saw his internist. Admitted to hospital Saturday 10/18. First seen by a neurologist Sunday 10/19 at which point he had a sensory level at mid-thigh and was grade 2-3 in all lower limb muscles. Initial suspicion was, naturally, Guillain-Barre, but CMAP amplitudes were normal, f-waves were preserved, and sural sensory potential was absent. Reflexes were 1+ at knees and ankle, toes down.

Brain and lumbar MRI ordered by internist were both normal. I saw him Monday 10/20 and there was a sensory level at umbilicus, grade 1-2 strength in legs. Arms and cranial nerves normal. CSF: protein 72 (diabetic), sugar 96, WBC 16, 93% of them mononuclear series cells. Cytology negative. MRI of thoracic spine appears to show patchy and longitudinal increase in signal over much of the thoracic cord.

Working diagnosis is (? post-infectious) inflammatory myelitis, and steroids were started 10/23. By the weekend his sensation was returning to legs ( to toes on right side) and he could wiggle toes and ankle again, although still too weak to move hips/knees. ANA, sed rate, Lyme serology, TB skin test all negative.

Any other thoughts or issues we have over looked? Alternate diagnoses?

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October 27, 2003

(c) 2003 M.H. Rivner