I have a difficult case that I hope you can help me with. A 30 year old woman who was in previously good health developed a 2 month history of a cough but without fever. On 6/29/00, she developed lower extremity paresis which progressed over the next few days to a complete flaccid paraplegia. She develop R eye blindness two days later. Evaluation at that time revealed that she had a T4 sensory level, a flaccid paresis of the lower extremities, loss of all sensation and incontinence. She was also also noticed to have a Marcus--Gunn pupil on the right.
On chest x-ray it was noticed that apical lesion felt to be consistent with TB. MRI of the spine revealed increased width from the mid-cervical to the mid thoracic cord with enhancement. The right optic nerve also showed enhancement. She underwent an L.P at that time which showed 117 WBC and 10 RBC (50 polys, 32 lymphs, 18 mono). Glucose of 41 and protein of 118. She was treated with steroids and multiple drugs for TB including Rifampin, INH, ethambutol, PZA and pyridoxine. Other work up at that time revealed a negative HIV, Normal B12 and folate and normal angiotensin converting enzyme. Her cultures grew out MAC and she was treated appropriately for that.
She noted some resolution of her paresis and did reasonably well until 7/28/00 when she develop acute shortness of breath, worsening of her paraplegia and numbness and weakness of her arms. She was transfered to our hospital on 8/2/00. At that time she had a T4 sensory level and a flaccid paresis of the lower extremities. She had no sensation of the lower extermities and both urinary and fecal incontinence. She had no lower extremity reflexes and bilateral Babinskis. She had no voluntary movements of her lower extremities but had ocassional spontaneous movements, very minimal. Her upper extremities were weak but distal muscles were weaker; 3/5 hand intrinsics, 4-/5 wrist muscles, 4/5 elbow ext and flexors and 4+/5 shoulders. Her neck and facial strength were normal. She had a glove distribution sensory loss in her upper extremities which definitely did not follow a dermatomal distribution. Sensation was good above the elbow and became progressively reduced from the elbow downward. She was areflexic in the upper extremities. She had a right Marcus--Gunn pupil with optic atrophy on the right. The remainder of her exam was normal including mental status.
Her imaging studies were repeated but showed no change. She had a CT of the chest which showed multiple cavitary lesions and a pulmonary embolus. She had deep vein thrombosis in the LE. A repeat HIV was still negative. She had a repeat LP which showed 2 RBCs, 10 WBCs (2 segs, 72 Lymphs and 25 monos). A protein of 91 and glucose of 52. She had nerve conduction studies done which showed very low amplitude motors in the lower extremities with borderline low amplitude motors in the upper extremities. The motor ncvs were minimally slowed. The upper extremity sensorys were normal but the surals were slight reduced in amplitude. Needle exam show minimal increases in insertional activity with no units seen in the lower extremities and poor volunatry activation in the upper extremities.
I am puzzled by the upper extremity findings which do not appear to be central. Also are these symptoms due to her infection or represent a separate demyelinating process? I do not have the exact NCV data with me now but will add them later.
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