PARAPARESIS CASE -3

This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

23 YEAR OLD BOY.

I  have been given a case data in the link given below to solve in an attempt to understand the topic of paraparesis. This may develop my competency in :

1. reading and comprehending given clinical data related to paraparesis including history , clinical findings, investigations .
2. come up with a diagnosis https://vaish7.blogspot.com/2020/05/medicine.html?m=1

Based on history :

The priority order of the patients are-

• bilateral lower limb weakness 
• tingling and numbness
• non-projectile ,non-bilious
• gluteal abscess
• psoas abscess

COMING TO A DIAGNOSIS-

What is the anatomical localization of site of lesion?

The examination features like :

• exaggerated reflexes of knee, ankle and supinator on right side
•  ankle clonus 
• positive babinski sign are suggestive of upper motor lesion but it also says she has bilateral hypotonia which is again suggestive of lower motor neuron lesion.

?? Can a patient have features of both the lesions?

 the patient may have initial period of hypotonia in the condition called SPINAL SHOCK which reflets decreased activity of spinal circuits suddenly deprived of inputs from motor cortex and brainstem.these lines are taken from the linkhttps://www.ncbi.nlm.nih.gov/books/NBK10898/

but since the cranial nerves are intact theres no brainstem pathology.Hence i think it could be in the motor cortex.

What is the most likely etiology and pathology ?
For this lets check the MRI and X-RAY of the patient.

findings :  multiple nodules in the pulmonary apices suggestive of pulmonary kochs and disseminated tuberculosis.