21 year old woman with paraplegia

21 year old woman, working as a nurse in an outside hospital, residing at Nalgonda presented to casualty on 26/8/2021 with the chief complaints of 
Fever since 4 months 
Generalized weakness since 4 months
Body pains along with multiple joint pains since 4 months
Cough since 1 month 
Vomiting 1 day back 
Unable to walk since 1 day
Unable to pass urine and stool since 1 day

She was born out of a non consanguinous marriage. She cried immediately after birth. 
At birth - she was in the hospital for 2 - 3 days for jaundice. 

Her father works as a shop keeper and her mother works at a chaat bandi. She has 2 elder sisters, both of her sisters work as the nursing staff. 

At 13 years of age, she had a history of fall following which she lost all her teeth.

She was apparently alright until 1 year back when she noticed swelling in her neck after she went for a checkup to a local hospital where she got diagnosed to be hypothyroid. She was started on Tab thyronorm 100mcg once daily.


Few months later she developed generalized weakness for which she paid a visit to a local hospital where in she was diagnosed with anemia for which she used vitamins supplementation for 2 days and stopped.

4 months back she developed low grade fever for 1 week which was nocturnal in variation, not followed by night sweats and was relieved by medications. Since then she has been experiencing low grade fever intermittently. She started experiencing generalized weakness and loss of appetite. 
She also tells us that she started experiencing extreme body pains to an extent that she stopped going to work. She even developed lower back pain followed by pain in her bilateral knee joints, wrists and elbow joints.

Since 1 month she has been having cough with scanty, non blood tinged  mucoid expectoration.
She paid a visit to a local hospital and received symptomatic treatment for a week.
1 day back she had 2 episodes of non projectile, non bilious, 
non blood tinged Vomiting.

On 26th of this month, she suddenly fell off from her bed at 7am in the morning when she tried to get up from her bed. Her mother and father had to lift her up and put her on the bed. She was unable to raise her bilateral lower limbs. Though she was able to move her toes with difficulty. Few hours later she started experiencing tingling sensation in her bilateral lower limbs. They assumed it was due to her generalized weakness and loss of appetite so she wasn't taken to any hospital. She even didn't pass urine and stool since morning. By evening after noticing that their daughter couldn't get up from her bed her parents got alarmed and got to our hospital.

On further questioning:

She gave no complains of difficulty in combing her hair, no difficulty in mixing of food. 
She had difficulty in getting up or turning in the bed

She gave no complaints of loss of smell, vision, diploma or eye movements, no difficulty in chewing, loss of sensation over the face, loss of taste, hearing and swallowing.

She says that she lost around 10kgs over the past 6 months 


On presentation to us:
Thin built woman 
She had pallor
Her vitals were stable
GCS - 15/15
She was conscious, coherent and cooperative with an 
MMSE of 30/30
Pupils bilaterally reacting to light
Bulk -               Right            Left
Mid arm        18cm            18cm
Forearm        13cm             13cm
Mid thigh      26cm             26cm
Leg            18.5cm           18.5cm

Tone          
UL                 Reduced bilaterally
LL                 Reduced bilaterally 

Power
UL                 4+/5              4+/5
LL                  2/5                2/5

Reflexes
B             3+                   3+
T             2+                   2+
S             3+                   3+
K             -                       - 
A             -                       -
P             Extensor bilaterally
Abdominal reflex - Absent 

Sensory system:
Priopioception lost upto the level of ankles
Vibration: Reduced in the lower limbs, more on the right side   
                     Right                   Left

Great toe  3 secs               4 secs
Ankle        3 secs               8secs
Knee         6 secs               8secs
Wrist        10 secs           11 secs
Elbow       11 secs           12 secs
Fine touch -  +                     +

Crude touch: 
On right side she complained of reduced touch on her right thigh
Spinal Tenderness- present throughout all the levels of spine 

Cranial nerves - normal 
Cerebellar signs - absent 


Lungs - Reduced breath sounds bilaterally in all the lung fields
Cvs - S1,S2 +
Per Abdomen- 
Bowel sounds +

USG abdomen from outside hospital done 1 week back:

Investigations done in our hospital:

  ? Pulmonary kochs
? Military TB

Investigations:
Hemogram: 
RBC: 4.09
WBC: 12300
Hb- 8.4
PLT- 4.8 lakh

Aptt- 32 sec
PT - 16 sec
INR. - 1.11
BT - 2 min 
CT - 4 min 
ESR - 90 mm in 1st hr

CUE: 
Albumin- nil
Sugars- nil
Pus cells - 2 to 3
Epithelial cells - 2 to 3

Blood urea- 22 mg/dl
Serum creatinine - 0.6 mg/dl 
TB- 0.70 mg/dl 
DB. - 0.19 mg/dl 
Na+ - 132 meq/lit
K+ - 3.4 meq/lit
Cl- : 94 meq/lit
ALP: 236 meq/lit
SGOT: 13 IU/LIT
SGPT: 10 IU/LIT
Serum protein: 6.5 gm/dl 
Serum magnesium: 2.2 mg/dl
Serum calcium: 9.6 mg/dl
Serum albumin: 2.4 gm/dl

28/7/21
Her sister and mother complained of her having left eyelid ptosis and she was complaining of diplopia in the morning 
Her weakness aggravated since yesterday 
She also complains of neck stiffness 

Neck stiffness+

Kernigs sign - couldn't be elicited as she is complaining of severe bilateral knee joint pains 

Power is now 0/5 in both the lower limbs

Reflexes - Bilateral finger flexion + on Biceps and supinator examination 



Lower limb reflexes absent 
Abdominal reflex absent

Sensory system:

Vibration Reduced upto the level of hip joint ( lesser on the right side)
Proprioception absent upto the level of ankles
Couldn't appreciate fine and crude touch below the level of umbilicus

Left eye ptosis +
Extraocular muscles - normal 
Pupils bilaterally reacting to light 
All the other cranial nerves normal

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