Case of the Month – October 2017

 

Get your thinking caps ready folks, for it’s time for the newest edition of Case of the Month.

 

The patient is a 28-year-old man with a history of SLE complicated by lupus nephritis, who presents with pressure-like mid-back pain since last night. He experienced no relief with oral naproxen, resulting in his presentation to the emergency department.  His last bowel movement and urination were approximately 8 hours prior to presentation and normal.  He denies any trauma, focal weakness, new numbness or tingling, fevers/chills, N/V, or any bowel or bladder complaints.  He does admit to not taking his lupus medications for about a month.  His only recent travel was to Georgia two months ago and Florida four months ago.  His lupus was discovered when he had nephrotic syndrome as a child, and he has never had a lupus flare, and he has not been on corticosteroids for the last year.

 

No known drug allergies

Medications: hydroxychloroquine 200 mg twice daily, mycophenolate mofetil 1g twice daily

PMH/PSH: As above, pulmonary embolism at age 15; bilateral hip surgery for avascular necrosis secondary to chronic steroids

SH: No toxic habits; denies previous sexual activity

ROS: As per HPI.

 

Physical Exam:

Vitals: T 97.4 (F), HR 63/min RR 22/min BP 127/73 mm Hg, SaO2 100% on room air

General: Young man sitting in bed, in no acute distress

HEENT: Sclera anicteric, no oropharyngeal erythema or exudates, moist mucous membranes

CV: Normal S1S2; no murmurs, rubs, or gallops

Pulm: Clear to auscultation bilaterally; no wheezes, rales, rhonchi, or crackles

Abdomen: Soft, mild/diffuse tenderness to palpation, dull to percussion

Rectal exam: Normal, no saddle anesthesia

Back: mild bilateral CVA tenderness

Neuro: CN2-12 intact.  Motor exam 5/5 bilateral upper and lower extremities; no sensory deficit; normal reflexes; no gait abnormality.

 

 

Labs:

Urinalysis: negative leukocyte esterase and nitrates, no WBCs or bacteria on micro

CMP: within normal limits

CBC: WBC 2.78 K/uL Hgb 13.5 g/dL Hct 39.2% Platelets 159 K/uL

 

EKG: Normal sinus rhythm, rate = 61/min

CXR: normal

Lumbar and Sacral Spine X-rays: Questionable L5 spondylolysis

 

After you give the patient APAP/oxycodone 5/325 mg once, he begins to complain of worsening weakness in his lower extremities, and requires assistance to walk to the bathroom. Once there, he finds he is unable to urinate.  A Foley catheter is placed, and he drains approximately 400 mL of urine. You order a CT of his head to rule out an acute stroke or intracranial hemorrhage.  Over the next three hours, the patient becomes unable to move his lower extremities, loses his bilateral patellar reflexes, and develops saddle anesthesia.  You consult neurology who recommend an MRI spine.  Over the following three hours, his paralysis rises to just below his xiphoid process.

 

Imaging

CT Head: No acute process

MRI Thoracic and Lumbar spine: No evidence of herniation, stenosis, or foramen narrowing.  Partially visualized high signal in the spinal cord to the level of the conus medularis which may represent demyelinating or inflammatory process, though primary vs metastatic malignancy cannot be excluded.

 

So…

  • What is your differential diagnosis for this patient?
  • Which, if any, further tests would you perform on this patient?
  • What therapeutic strategy would use for this patient?
  • What is his ultimate disposition? Is there any additional information that you need prior to making this disposition decision?

Good luck!

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rithvikb

Resident Physician, EM/IM  

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1 comment for “Case of the Month – October 2017

  1. Kylie Birnbaum
    October 9, 2017 at 2:42 pm

    Nice Post, Rithvik.
    Ddx: Transverse Myelitis, guillian barre, epidural hematoma or epidural abscess, multiple sclerosis, and TUMAAH. I think transverse myelitis is most likely especially with a history of an autoimmune disorder and no definitive spinal cord compression seen on MRI.
    Consult neuro, consider an LP looking for leukocytosis and elevated protein.
    Treatment starts with steroids, maybe plasm exchange, admission with ICU consult. Get a NIF, and closely monitor in case he progresses and requires intubation.

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