Differential Diagnosis of Quadriparesis in an Otherwise Healthy Adult Male by a Physical Therapist

Abstract

HISTORY: A 52-year-old male was referred to Physical Therapy (PT) by his primary care physician for progressive quadriparesis related to suspected peripheral neuropathy (PN). The patient was healthy and active until two years prior when he began experiencing weakness and paresthesias in both hands. This progressed to his right lower extremity, then all four extremities, and by the time of the PT evaluation, the patient was no longer able to stand. He also endorsed several episodes of bladder incontinence, constipation, and painful muscle spasms. He was scheduled for imaging of the spine and a follow-up with his physician in two months. Review of the medical record revealed that the patient was evaluated by a physical therapist nine months prior. His presentation then was consistent with the working diagnosis of PN. However, a sinister diagnosis was suspected due to the involvement of all four extremities without risk factors for polyneuropathy. At that time, no further steps were taken as the patient did not follow up in clinic. PHYSICAL EXAMINATION: The patient presented in a wheelchair, though was unable to propel or stand without assistance due to significantly worsening weakness. Neurologic exam revealed several upper motor neuron signs including hypertonicity and hyperreflexia. This presentation was no longer consistent with the working diagnosis of PN (see table).Table: No title available.DIFFERENTIAL DIAGNOSIS: 1. Cervical spine stenosis with myelopathy 2. Space occupying lesion in cervical region 3. Progressive motor neuron disease TESTS AND RESULTS: Cervical/Thoracic spine MRI: 12.4 cm intradural intramedullary mass from C5 to T5, likely related to multiple tumoral cystic areas, with syrinx from T3 to T4 FINAL DIAGNOSIS: Intradural intramedullary ependymoma extending from C5 to T5 with associated syrinx TREATMENT AND OUTCOMES: Based on the examination and presence of multiple red flags, the physical therapist referred the patient to the Emergency Department for further evaluation.