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.
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.
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
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.
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.
- 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?