Return of the trouble
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Mr. GCSR, a 47-year-old male shopkeeper, presented with weakness in his lower and upper limbs, tingling and numbness in his hands and feet, and bladder disturbances over the past few months. He had a history of tuberculosis meningitis 20 years ago. MRI showed a syrinx from C3 to D11 with tuberculous arachnoiditis, likely causing polyradiculoneuropathy. Treatment with antitubercular drugs and steroids led to improvement of symptoms. The case highlights the importance of considering recurrent tuberculosis in patients with syringomyelia and arachnoiditis, as timely treatment can resolve symptoms.
Return of the trouble
- 1. RETURN OF THE TROUBLE-TUBERCULOUS ARACHNOIDITIS WITH SYRINGOMYELIA-A CASE REPORT BY-Akash Srivatsav T Moderated by- Dr.N.V.Sundarachary MD;DM Dr.U.Veramma MD;DM Dr.R.Lalitha MD.
- 2. Patient Particulars Name Mr.GCSR Age 47 years Sex Male Marital status Married with a child Occupation Shopkeeper Address Guntur Regd no A030616 DOA 14-07-2014 DOD 21-07-2014
- 3. Chief symptoms of- • Weakness of both lowerlimbs since six months • . Weakness of both upperlimbs for three months. • Tingling, numbness and paraesthesias of two months duration. • Bladder diturbances of two months duration
- 4. History Of Present Illness • Weakness of both the lower limbs in the form of inability to getup from sitting and Squatting positions, climbing up-stairs, auto-rikshaw and bus which was associated with stiffness.
- 5. Weakness of both hands while performing fine finger movements like mixing food and writing for three months.
- 6. Tingling, numbness and paraesthesias of both hands and feet for three months which was first observed in the feet with no subjective loss of sensations. Girdle sensation around the upper trunk below the nipples.
- 7. Micturition disturbances like urgency, frequency, overflow incontinence. Sexual dysfunction in the form of erection and ejaculation difficulties
- 8. No history of • Speech and language disturbances, • Disturbances of higher mental functions in any form, • Cranial nerve involvement in any form, • Weakness of proximal upperlimb and distal lowerlimb musculature.
- 9. No history suggestive of- • Involvement of cerebellum and meninges, • Raised IntraCranial Tension, • Gait disturbances.
- 10. Past history • Diagnosed to have TB meningitis 20 years ago and received ATT for 2 years. • Underwent lumbar laminectomy 20 years back.
- 11. General condition on examination- Conscious, coherent and oriented. Moderately built and nourished No- Pallor Icterus Cyanosis Clubbing Lymphadenopathy Pedal oedma
- 12. Vitals- Afebrile BP-130/80 mm of Hg PR-78/min RR-16/min
- 13. CNS examination- Right hand dominant Speech and language – Normal Higher mental functions- Normal Cranial nerves- Normal
- 14. Motor examination Bulk –Normal in all the four limbs Tone- Spasticity of all the four limbs
- 15. Power - Upper Limbs Muscle group Right Left Shoulder 5/5 5/5 Flexion 5/5 5/5 Extension 5/5 5/5 Abduction 5/5 5/5 Adduction 5/5 5/5 Elbow 5/5 5/5 Flexion 5/5 5/5 Extension 5/5 5/5 Wrist 5/5 5/5 Flexion 5/5 5/5 Extension 5/5 5/5 Hand grip 90 % 90 %
- 16. Lower limbs Muscle group Right Left Hip 4/5 4 /5 Flexion 4/5 4/5 Extension 4/5 4/5 Abduction 4/5 4/5 Adduction 4/5 4/5 Knee 5/5 5/5 Flexion 5/5 5/5 Extension 5/5 5/5 Ankle 5/5 5/5 Dorsi flexion 5/5 5/5 Plantar flexion 5/5 5/5 EHL Normal Normal EDL Normal Normal
- 17. Reflexes Superficial reflexes – Present Plantar : Bilateral Equivocal Deep Tendon Reflexes Biceps Triceps Supinator Knee Ankle Right 3 + 3+ 3+ 3 + Absent Left 3+ 3+ 3+ 3+ Absent
- 18. Sensory Examination Cutaneous – Pain and Temperature intact Joint position sense and vibration – Absent in all the four limbs *In upper limbs till the wrist joints *In lower limbs upto the knees Loss of vibration upto – T4 vertebral level No meningeal signs No signs of raised ICT
- 19. Provisional Diagnosis Spastic quadriparesis with peripheral neuropathy
- 20. Differential diagnosis • Spinal tuberculosis • Other causes of myelopathy.
- 21. INVESTIGATIONS : Investigation Result Hb % 10.2gm/dL RBS 78mg% ESR 40mm in 1st hr Blood Urea 14mg% Serum Creatinine 0.8mg% Sodium 157mEq/L Potassium 4.1mEq/L Chloride 126mEq/L HIV I Non reactive HIV II Non reactive HbsAg Negative HCV Negative
- 22. CSF Analysis Total Count : 696 cells/cumm Differential Count : Neutrophils - 80 Lymphocytes- 20 Protein : 855 mg/dL Glucose : 100mg/dL PANDYS : Positive ADA – CSF Fluid : 0.9 U/L PCR for TB antigen : Positive
- 23. IMAGING STUDIES
- 26. MRI of whole spine • Syrinx extending from C3 to D11 with maximum diameter measuring 5.8mm in the dorsal region. • Status post laminectomy at L4 - L5 level. • Bilateral facetal hypertrophy at L4 – L5 level. • Posterior central protrusion at L4 – L5 level causing impingement over the thecal sac with narrowing of bilateral neural foramina causing compression over the exciting nerve roots. • Crowding of thecal sac at L4 level with increased epidural fat at this level. • Loculation of CSF opposite from D4 to D6 level on the posterior aspect. Features represent syrinx with associated sequelae of arachnoiditis.
- 27. Nerve conduction studies- Decreased CMAP amplitudes. Absent F-waves Absent SNAPs Axonal motor sensory polyradiculoneuropathy .
- 28. Final diagnosis Type-III-C Syringomyelia Extending from C3-D11 with tuberculous arachnoiditis leading to Polyradiculoneuropathy.
- 29. Treatment • Tab Rifampicin 600mg OD • Tab Isoniazide 450mg OD • Tab Pyrazinamide 750mg BD • Tab Ethambutol 1000mg OD • Tab Prednisolone 1mg/kg body wt in tappering doses • Tab Tolperisone hydrochloride 150mg OD • Tab Pyridoxine 40mg OD • Tab Calcium OD • Syp Potassium
- 30. Outcome • The patient reported improvement of I. Tingling, numbness and parasthesias of hands and feet. II. Weakness of the upper and lower limb musculatures. III. Micturition disturbances.
- 31. Discussion Tuberculosis remains one of the treatable but troublesome disorders affecting central nervous system.
- 34. A high index of suspicion and detailed evaluation revealed the presence of a coexisting, medically treatable condition in the patient who also had syringomyelia which however did not explain his symptomatology. Also surgery is deferred in our patient.
- 35. Conclusion Tuberculous arachnoiditis resulting in syringomyelia is a rare and late complication. Our patient has recurrence of tuberculosis which produced the clinical picture .Indepth knowledge of the pathophysiology and meticulous workup are the cornerstones in successful management of such cases .
- 36. Bibliography • Adams and Victor's Principles of Neurology, Ninth Edition • Bradley's Neurology in Clinical Practice, 6th ed.
Editor's Notes
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