Bilateral Lower Limb Weakness Research Articles

A Rare Case of Guillain–Barré Syndrome with Signs of Meningeal Irritation and Treatment-Related Fluctuations/Relapse

Abstract Guillain–Barré Syndrome is an acute inflammatory demyelinating polyradiculoneuropathy that can present at any age. The presentation of Guillain–Barré syndrome may be variable as the classic symptoms of areflexia and flaccid paralysis may or may not be present. Here we reported a case of a 15-year-old male patient who presented with complaints of weakness in bilateral lower limbs with inability to sit along with slurred speech and drooling of saliva with positive meningeal signs like neck stiffness and Kernig's sign. His symptoms improved with immunoglobulin therapy. Five days later, the child again had pain and increased weakness with increased work of breathing for which repeat dose and course of immunoglobulins were given. As patients with signs of meningeal irritation may suggest other diseases such as meningitis, it is important to consider atypical cases of Guillain–Barré syndrome along with treatment-related fluctuations as observed in our patient.

Guillain-Barré syndrome and COVID-19 vaccination: A systematic review

Background. This systematic review evaluated the studies conducted on Guillain-Barré syndrome (GBS) due to COVID-19 vaccination to clarify any possible connections and the type of vaccines causing GBS. Methods. A comprehensive search was performed on July 2021 through MEDLINE (via PubMed), Scopus, Cochrane, and Web of Science databases to detect published and unpublished papers. Our PICO was all COVID-19 vaccinated individuals as the population, COVID-19 vaccines as the intervention, and patients experiencing GBS following COVID-19 vaccination as the outcome. Critical appraisal instruments from the Joanna Briggs Institute case series or case report were used to evaluate the quality of included studies. Results. In the present systematic review, 12 case reports and case series including 21 patients were assessed. More than half of the patients were male, and the mean age of male patients was lower than females. In terms of vaccine type, the most common kind of vaccine injected was Oxford/AstraZeneca, and all the cases except one patient had received only one dose of the vaccine. Regarding the interval between receiving the vaccine and the onset of GBS symptoms, the mean duration was 14 days. The lowest mean time interval between receiving the vaccine and the onset of symptoms of GBS was related to the unnamed vector-based COVID-19 vaccine, and the highest was associated with Oxford/AstraZeneca. Conclusion. Through this systematic review of case reports, we neither attempt to establish nor rule out a causal link between the COVID-19 vaccine and GBS, because such a link requires extensive case-control studies. However, we must highlight any events that may occur following the injection of existing vaccines. Practical Implications. The most common symptoms seen in patients experiencing GBS after vaccination included progressive bilateral lower limb weakness, paresthesia, numbness of limbs, generalized body aches, and back pain.

Devastating Cause of Low Back Pain: A Case of Spinal Cord and Vertebral Body Infarction

A 62-year-old male presented with sudden onset low back pain and bilateral lower limb weakness while playing Mahjong continuously for an hour. There was no history of trauma. He was a chronic smoker with hypertension and hypercholesterolemia but was not on any regular medication. He had no known family history of neurological or autoimmune disease.

Butterfly Vertebra and other Congenital Vertebral Anomalies in a Child

Butterfly vertebra is a rare birth defect of the spine which is generally asymptomatic. Fewer cases of this defect are reported till now. Here we have reported a case of a 2 year old female baby, who presented with bilateral lower limb weakness and an involuntary passage of stools and urine since birth. Magnetic Resonance Imaging (MRI) confirmed the cause, which showed the presence of syrinx in the spinal cord extending from the vertebral level of T9-T11, butterfly vertebra at T11 level and spina bifida occulta. The neurological examination revealed decreased power in the bilateral lower limbs and bladder- bowel involvement.

Sudden Onset of Paraplegia With Rapid Progression to Tetraplegia in a Middle-Aged Man: What is the Diagnosis?

Anterior cord syndrome due to anterior spinal cord infarction is commonly described in the medical literature, however, in clinical practice, this entity is rarely encountered.
 We present a 58-year-old man with sudden onset of bilateral lower limb weakness, followed by bilateral upper limbs involvement. Magnetic resonance imaging (MRI) of the whole spine was performed and he was diagnosed to have anterior spinal cord infarct.
 The characteristic imaging findings were highlighted.

A novel compound heterozygous SPG7 variant is associated with progressive spastic ataxia and persecutory delusions found in Chinese patients: two case reports

BackgroundHereditary spastic paraplegia 7 (SPG7) is one of the subtypes of autosomal-recessive hereditary spastic paraplegia, which is a clinically heterogeneous neurodegenerative disorder. SPG7 often displays a complicated phenotype, including optic atrophy, ophthalmoparesis, and impaired emotional communication. In the Chinese population, sporadic cases of SPG7 variant-associated spastic ataxia are rarely reported.Case presentationWe carefully analysed the clinical features, imaging and genetic tests of two sporadic patients with SPG7, both from the Hebei region of China. One patient presented with progressive bilateral lower limb weakness, spastic-ataxia and no cognitive impairment. Brain MRI revealed mild cerebellar atrophy. Genetic analysis revealed c.1150_1151insCTAC (p.G384Afs*13) frameshift variant and exon1-3 heterozygous deletion. The other patient presented with progressive bilateral lower limb weakness, ataxia, dysarthria and a mild psychosis associated with persecutory delusions, which drew almost no attention, in addition to mild cognitive impairments characterized by a decrease in verbal memory and executive function. Genetic analysis identified two heterozygous variants in the SPG7 gene: c.1150_1151insCTAC (p.G384Afs*13) and c.1496delC (p.Q500Sfs*13).ConclusionsThe c.1496delC (p.Q500Sfs*13) variant in exon 11 has not been reported before. The c.1150_1151insCTAC variant is speculated to be a hotspot variant in the Chinese population. Patients with SPG7 may have cognitive impairments and psychosis, displaying specific characteristics, which should be of concern.

Mcardle’s Disease Complicated by Acute Renal Failure

McArdle’s disease is a Glycogen storage disease (type V) which is caused due to the inherited deficiency of myophosphorylase enzyme required for the breakdown of muscle glycogen. It typically presents with complaints of exercise intolerance, early fatigability, and muscle aches. The disease can be complicated by rhabdomyolysis in severe cases. We present the case of a 27 years old male with McArdleʼs disease who presented with bilateral lower limbs weakness associated with muscle aches and dark colored urine which later turned into anuria. Diagnosis of acute renal failure complicating rhabdomyolysis in background of McArdle’s disease was made. Keywords: Glycogen storage disease, Glycogen phosphorylase, myopathy, rhabdomyolysis

Management of a rare case of isolated U-shaped displaced sacral fracture in a young female high school student

Sacral fractures in young healthy patients are usually linked to high-energy trauma. They are often associated with multiple other injuries. Isolated sacral fractures are rare and can be easily missed in the absence of other surrounding pelvic or spinal injuries. In this article, we present a rare case of isolated U-shaped displaced sacral fracture despite the high-energy mechanism of injury being missed on initial presentation. This is a 17-year-old healthy female who presented to the emergency department after falling from five-meter height. She complained of lower back pain and inability to ambulate. Physical examination revealed significant sacral tenderness, bilateral lower limb weakness and hypoesthesia, anesthesia of the saddle area, weak anal tone and absent anal reflex. Initial radiographs showed no apparent fractures. Further imaging by pelvic computed tomography, however, revealed an isolated U-shaped displaced sacral fracture. The patient was treated by decompression and lumbopelvic fixation by triangular osteosynthesis and iliosacral screw. This fixation method restored stability of the spinopelvic junction and allowed for early mobilization. At her 18-month follow-up visit, she showed minimal disability score (10%) on the Oswestry Disability Index. In conclusion, sacral fractures are considered exceedingly rare to occur in isolation and in young healthy patients.

Spinal Cord Presentation of Biopsy-Proven PET-Positive Giant Cell Arteritis.

A 63-year-old man presented with sudden bilateral lower limb weakness and right sided sensory loss to pain and temperature, on a background of recently diagnosed biopsy-negative giant cell arteritis (GCA) treated with prednisone 50mg. ESR was normal. Somatosensory evoked potentials revealed central conduction delay. PET/CT imaging revealed major vessel hypermetabolism (Figure 1), indicative of active GCA confirmed on repeat temporal artery biopsy (Figure 2). Spinal cord involvement was suspected; intravenous steroids, cyclophosphamide, followed by tocilizumab were commenced with good response. Clinicians should be aware of rare manifestations of GCA1 and PET-CT might be helpful in evaluation of disease activity2.

A Missed Diagnosis of Guillain-Barre Syndrome Masquerading As Stroke in an Acute Medical Unit: A Case Report

An elderly woman aged 66 presented to a general hospital with left-sided facial paresis, bilateral lower limb weakness, and back pain. After undergoing clinical assessments and investigations, she was diagnosed and treated as a case of acute stroke. Two weeks later, she was repatriated to our hospital for neuro-rehabilitation. Unconvinced, we revisited her clinical history and, after a thorough physical examination, made a clinical diagnosis of GuillainBarre Syndrome (GBS), i.e., confirmed by electrophysiological studies. She was treated with intravenous immunoglobulin and made a complete recovery 6 weeks later.
 This case highlights an infrequent presentation of GBS as a stroke-mimic. It re-emphasizes the need to maintain a high index of clinical suspicion for similar expressions, especially in busy acute medical units. Such cases are easily missed if basic clinical skills, such as good historytaking and thorough physical examination, are glossed over. Despite time constraints, these skills are indispensable in clinical practice.

ACUTE DISSEMINATED ENCEPHALOMYELITIS AS A COMPLICATION OF SCRUB TYPHUS

Scrub typhus is an acute febrile illness usually characterized by eschar, lymphadenopathy, multisystem involvement caused by Orientia tsutsugamushi. Scrub typhus as a cause of acute disseminated encephalomyelitis (ADEM) is extremely rare. This is a case report of a 40 years old female presenting with sudden onset altered sensorium, bilateral lower limb weakness with difculty in walking, irrelevant speech, urinary and bowel retention since two days, high grade intermittent fever associated with headache and multiple episodes of vomiting for past one week. Cerebro spinal uid study showed lymphocytic pleocytosis with mildly increased protein. MRI brain showed multifocal encephalitis & MRI spine revealed demyelination at spinal cord suggestive of ADEM. Paired CSF & serum scrub typhus IgM ELISA was found to be positive. She was ultimately diagnosed as a case of scrub typhus complicated with ADEM. After treatment with doxycycline and methylprednisolone patient improved dramatically without any residual neurological decit during discharge. This case report highlights that scrub typhus should be included in the differentials in patients presenting withADEM for early diagnosis and treatment in order to reduce mortality and morbidity.

A case of transverse myelitis post COVID-19 infection in Pakistan

Background. COVID-19 emerged in Wuhan, China and spread rapidly, becoming a global health pandemic. The condition, apart from its typical respiratory presentation, may also cause neurological complications. Case presentation. A 35-year-old, ex-smoker presented with bilateral lower limb weakness associated with urinary incontinence and constipation following the resolution of a suspected COVID-19 infection. His MRI-Spine showed areas of abnormal densities confirming the diagnosis of transverse myelitis. On the presence of positive SARS-CoV-2 antibodies, COVID-19 was concluded as the pathological trigger for the condition. He was treated using Methylprednisolone and Plasmapheresis with supportive limb physiotherapy which led to a partial recovery of the patient’s disability. Conclusion. This is the first case of TM associated with COVID-19 in Pakistan and considering the current scenario of a global pandemic, COVID-19 needs to be considered as an important differential for not only TM but other neurological manifestations like encephalitis, neuritis etc.

Teaching NeuroImage: Thickened and Enhanced Cauda Equina as a Manifestation of Acute Lymphoblastic Leukemia Relapse.

A 20-year-old man with a history of B-cell acute lymphoblastic leukemia (ALL) in remission reported a 2-week history of bilateral lower limb weakness. Electrophysiologic examination showed prolonged latency of F-wave of bilateral tibial nerves. The CSF opening pressure was increased (>30 cm/H20), with elevated protein level (1683 mg/L, RI 150–400 mg/L), decreased glucose concentration (5.94 mg/dL, RI 50.4–80.64 mg/dL), and pleocytosis (854/mm3, RI < 10/mm3) in CSF. Flow cytometry assays for detecting minimal residual disease in CSF disclosed numerous lymphoblasts (CD45+, CD19+, CD34+, CD10+, CD38±, and CD20−), and lumbosacral MRI showed thickened and homogeneously enhanced cauda equina, which were consistent with nervous system relapse of B-cell ALL (Figure).1 Cauda equina involvement as a manifestation of ALL relapse is rare, and lumbosacral MRI markedly improved diagnosis.

Sudden Onset of Paraplegia With Rapid Progression to Tetraplegia in a Middle-Aged Man: What is the Diagnosis?

QUESTIONA 58-year-old man, known case of diabetes mellitus, hypertension presented with sudden onset of bilateral lower limb weakness while resting, to the nearby medical centre. The weakness later progressed to involve bilateral upper limbs, leaving him tetraplegic, 3 hours from symptom onset. He denied chest or back pain. His electrocardiogram (ECG) revealed sinus rhythm, without any acute ischemic changes. There was no preceding febrile illness or injury. His case was referred to our centre with the impression of Guillain-Barre Syndrome (GBS).

Surgical management of spinal dural arteriovenous fistula – A single centre experience

IntroductionSpinal dural arteriovenous fistulas (sdAVF) are vascular malformations occurring in the spine which are commonly seen in elderly men in the sixth and seventh decade of life [1]. Patients initially present with non-specific symptoms, eventually progressing to motor, sensory, and autonomic disturbances. Due to delayed presentation and non- specific symptoms, sdAVF are often undiagnosed, leading to delay in treatment. AimWe report 4 cases of sdAVF who underwent microsurgical treatment. MethodsAll the patients presented with insidious onset, gradually progressive bilateral lower limb weakness, paraesthesia, and urinary incontinence. MRI revealed subarachnoid flow voids and spinal cord T2 signal hyper-intensities in all 4 patients. Spinal angiogram showed fistula at T10,11 level in one patient, L1 level in two patients and at L5 in one patient. In these patients the artery supplying the AV fistula share a common pedicle with either artery of Adamkiewicz, Anterior spinal artery (ASA) or posterior spinal artery(PSA). Hence, the use of embolic agent in these patients to occlude the fistula carries a high risk of cord ischemia. In all these patients microsurgical procedure was carried out with successful outcomes. ResultsAll the 4 patients improved neurologically after surgery. Lower limb weakness and sensations improved early, but improvement of bladder function was delayed. Functional outcome was reassessed 6 months after the procedure using Modified Aminoff and Logue’s scale, which was compared to pre-operative functional status of the individual. ConclusionTimely intervention of sdAVF is challenging because of its nonspecific presentation. MRI offers a clue to the diagnosis while spinal angiography confirms the diagnosis and angio-architecture will decide the suitable mode of treatment. Though endovascular treatment is a viable option surgery is the gold standard [14].

An Unusual Case of Pancytopenia: The Lessons Learnt.

Pancytopenia is a common hematological abnormality encountered in clinical practice. We here report a 36-year-old male who presented to emergency department with complaints of weakness of bilateral lower limbs, burning sensation in all four limbs with history of loose stools, and vomiting 5 days back. The complete blood count of patient showed pancytopenia with no circulating atypical cells. Bone marrow examination performed showed nonspecific but characteristic findings. After excluding the possibility of infective etiology, a possibility of heavy metal toxicity was suspected in multidisciplinary meeting. The urine and blood levels of arsenic done came out very high, and a diagnosis of arsenic poisoning was made. Patient had multisystemic involvement with features characteristic of arsenic poisoning. The present case was a diagnostic challenge in face of nonforthcoming history. This case beautifully highlighted the importance of multidepartmental approach in such cases to arrive at unerring diagnosis and the unique bone marrow findings, although nonspecific were sufficient enough to indicate the possibility of acute insult to the hematopoiesis.How to cite this article: Nair RR, Singh PK, Sharma J, Gambhir I, Khanna S, Jain AK, et al. An Unusual Case of Pancytopenia: The Lessons Learnt. Indian J Crit Care Med 2022;26(1):141–144.

A Rare Case of Sequestered Intervertebral Disc Mimicking a Tumour

Although intervertebral disc herniation is commonly seen in clinical practice, spinal canal migration of disc fragments is rarely found and can cause a diagnosis dilemma. Intervertebral disc herniation is defined as displacement of disc material beyond its anatomical space. The lumbar spine is the most commonly affected; mostly L4/L5 and L5/S1 region. Disc sequestration refers to the migration of herniated disc fragments into the epidural space, or in rare cases intradural space. Hereby we present a case of sequestered intradural disc at the level of L3/L4 level mimicking a spinal tumour. A 46-year-old man presented with complaints of dull-aching bilateral lower limb pain for the past five years. Then, for the past three months, he experienced numbness over bilateral feet. For the past one month, there is weakness of bilateral lower limbs and he was unable to stand and walk. There is no erectile dysfunction, urinary and faecal incontinence. There was no history of trauma. Examination revealed sensory and motor deficits over bilateral lower limbs from level L3 onwards. There is no spine tenderness. Bilateral straight leg test were negative. MRI spine reported as L3/L4 intradural spinal lesion that demonstrates T1W iso-intensity, predominantly low signal intensity on T2W with minimal area of hyperintensity within. Lesion measured 1.3 x 1.4 x 2.5cm. Laminectomy was done and intra-operatively it was noted sequestered disc material protruding into dura from L2/L3 up to L4/L5. Post-operative period was uneventful and patient regained full muscle power by post-operative day-3. MRI is the gold standard diagnostic tool for spinal pathologies, nevertheless migrated disc fragments can be mistaken for spinal tumour. Hence, it important to keep intervertebral disc prolapse as a differential. In view of the excellent prognosis in these cases, it is not advisable to delay surgery with additional invasive investigation

Management of multiple sclerosis through Ayurveda: A case report

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problem between brain and rest of the body. Steroids are the drugs of choice in conventional systems but fail to provide a complete cure. There is no direct reference to the disease in Ayurveda, but based on the clinical picture, treatment can be planned. A 28-year-old male patient diagnosed with MS approached the Panchakarma outpatient department with chief complaints of difficulty in balancing while standing and walking, weakness in bilateral lower limbs, and lower backache. On examination of presentation according to Ayurveda, this manifestation was diagnosed as a type of Vata vyadhi (~diseases caused by a Vata dosha). Considering the case, different Panchakarma (~five bio-purification therapies) procedures including Ruksha churna pinda swedana (~dry fomentation), Takradhara (~therapeutic buttermilk dripping), Kshara basti (~therapeutic enema therapy by alkali substance), Snehapana (~internal administration of medicated lipids), and Virechana (~therapeutic purgation) followed by Kalabasti (~therapeutic enema therapy) and Nasya (~intranasal drug administration) were adopted along with Shamana (~palliative) therapy. After completion of 45-day stay in hospital and one month Shamana treatment on follow-up, considerable improvement was recorded in subjective parameters. Assessments were made using the Kurtzke Expanded Disability Status Scale which was 8 before treatment and decreased to three after follow-up. The Functional Assessment of MS was reduced from 158 to 102. The Visual Analog Scale which was 8 before treatment was decreased to 1 with increased quality of life according to the SF-36 Quality of Life Scale.

DeBakey type 1 aortic dissection presenting as abdominal pain with paraplegia: case report and literature review

Background: Aortic dissection (AD) is a catastrophic condition that represents a challenging diagnosis for emergency physicians. Its presentation can vary widely and may present with non-specific symptoms. A delay in the diagnosis of AD is associa ted with a high rate of morbidity and mortality. Case Presentation: A 77-year-old man presented to the emergency department with a history of acute epigastric abdominal pain and bilateral lower limb weakness. A suspected AD was confirmed by urgent computed tomography angiography in less than 1 hour; which showed extensive dissection of his aorta from ascending part up to the abdominal aorta; &amp;quot;DeBakey1.&amp;quot; The emergency complex aortic repair was then performed by the cardiothoracic surgical team that had resulted in a successful fortunate recovery. Conclusion: DeBakey type1 AD is a serious cardiovascular surgical emergency, with a dismal prognosis if missed in the emergency room. Our prompt diagnosis and expedited approach in handling this case led to successful recovery.

Tropical spastic paraparesis-like illness in an HIV-Infected child

Human T-cell leukemia virus type 1(HTLV-1) is the etiological agent responsible for the clinical entity of tropical spastic paraparesis/HTLV-1-associated myelitis (TSP/HAM). HTLV-1 and HIV-1, being related retroviruses, coinfection with both is a well-recognized phenomenon but rarely reported in children. We describe a 5-year-old boy with no previously known comorbidity who presented with bilateral lower-limb weakness and calf pain along with urinary retention. Imaging confirmed the presence of myelitis. Investigations showed elevated creatine phosphokinase(CPK) values suggestive of myositis. It was later learned that the parents of the child were on treatment for HIV infection. Antibodies for HIV were positive by ELISA, and in view of the clinical picture, probability of a TSP-like illness as the initial presentation of a hitherto undiagnosed HIV infection was considered. TSP/HAM is an important yet underrecognized cause of spinal disease, especially in HIV-infected individuals. Certain features such as elevated to normal CD4 counts, absence of significant sensory symptoms, and associated myositis may serve as subtle clues to underlying HTLV-1 infection.