Case of 23year old with paraparesis

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

You can find the entire real patient clinical problem in this link here..
https://vaish7.blogspot.com/2020/05/medicine.html?m=1
Following is my analysis of this patient's problem:

Following is my analysis of this patient's problem

The problems in order of priority according to my perspective are:
  1. The weakness of bilateral lower limb associated with tingling and numbness
  2. A gluteal and scrotal abscess (history of frequent falls)

Reasons:

    Bilateral lower limb weakness associated with tingling and numbness from 5 days by the time case registered (Admission date: May 14, 2020).

Paraparesis:
    Partial paralysis of lower limbs (Source: Oxford dictionary)
    -It can be due to trauma, vitamin B12 deficiency, neuromuscular disease, and any peripheral vascular disease.
    But here, with the symptoms, tingling & numbness it can be concluded as a neuronal problem.

On examination:

1. Higher mental functions - Normal
2. Cranial nerves - Intact
3. Motor system: 
                a) Bulk - Normal 
                b) Tone - Hypotonia in lower limbs 
                c) Power - Lower limb ( Right: 2/5, Left: 0/5) 
                d) Reflexes - Ankle clonus absent in left 
                                   - Primitive reflex absent
                                   - Involuntary movements absent
4. Sensory system - Normal
5. HIV - Nonreactive

Upon investigation, X-ray and MRI:
    There is a significant enhancement that represents meningeal exudates. The following lesions in MRI suggest disseminated tuberculosis.




Anatomical location for the cause of Paraparesis:

    From the above examinations and reports, the anatomical location of the present paraparesis lies in anterior right and left cerebral hemispheres, the midline of the falx cerebri, and pyramidal tracts.
(- Bilateral hypotonia suggestive of LMN lesions
 - Hyperreflexia of knee and ankle reflex suggestive of UMN lesions
 - Ankle clonus suggestive of UMN lesion)

Possible etiology of Paraparesis:

    The possible etiology might be the spread of Mycobacterium Tuberculosis as shown in the following flowchart.


    And further causing infarcts in pyramidal tracts thereby resulting in Paraparesis.

Possible investigations:

    MRI suspects Mycobacterium Tuberculosis. Therefore, further investigations are needed as mentioned below.
  1. Sputum microscopy
  2. CBNAAT
  3. Bronchoscopy followed by bronchoalveolar lavage study
  4. Culture of abscess fluid

Provisional diagnosis from the case:

    Paraparesis with L4, L5 infective spondylodiscitis with left psoas abscess with ring-enhancing lesions in right and left cerebral hemispheres with healing ulcer in the right gluteal region secondary to drained gluteal abscess with pyocele left side operated 10 days back (Admission date: May 14, 2020).

Therapeutic modality:

  1. Anti-Tubercular Therapy (ATT)
  2. Tab. Benadon
  3. Tab. Pregabalin
  4. Oint. Megaheal for local application
  5. Frequent change of position

References:

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