A 64-year-old dance teacher with a history of type 2 diabetes and hypertension presented with interscapular pain and sudden onset of weakness in all limbs, affecting the legs more than the arms. During the 2 weeks between presentation to a rural doctor and admission to the hospital, the weakness was static, but the patient developed urinary incontinence that required bladder catheterization. He had been taking simvastatin, enalopril, gliclazide, and metformin. One year ago, he had had a toe-ectomy for an ischemic diabetic toe.
On examination, he was apyrexial. Atrial fibrillation was present. The rest of the system examination was normal. There was local spinal tenderness over the dorsal spine. The patient had no meningism, but on flexion of the neck, pain was referred to the interscapular region. He was fully conscious, and cranial nerves were normal. Tone was normal, but occasional spontaneous jerks were observed in the legs. Power was reduced to grades 3 and 4/5 in the arms and 0 and 2/5 in the legs. Tendon reflexes were normal in the arms and absent in the legs. The plantar responses were extensor. There was no sensory deficit.
ASSESSMENT
The patient was assessed as having a spinal cord lesion. Because of the acute onset, cord ischemia or compression was suspected.
INVESTIGATIONS
Spinal x-rays showed cervical degeneration. Blood tests were negative for retroviral disease and syphilis. The hemoglobin count was low (10.9 g/dL), the white blood cell count was elevated (14,060/mm3), the erythrocyte sedimentation rate was elevated (109 mm/hour), and the C-reactive protein level was elevated (119 mg/L).
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Published in Journal Watch Neurology March 31, 2009
Reader Remarks:
Review and add to remarks on this article
- spinal cord infarction
marc allewaert, private retired neurologist, 1 Apr 2009 1:33 PM EST
I think the patient suffered from a spinal cord ischemic lesion due to atherosclerosis ( diabetes ! ) of the... [more] - quadriparesis
Rabia Akbar Vali, C.P.H., 1 Apr 2009 1:33 PM EST
epidural abcess - Aortic dissection
Carlos Alberto Leite, 1 Apr 2009 1:33 PM EST
This is one of the great Professor William Proctor Harvey, a master on the art of physical examination in cardiology... [more] - Transverse myelitis
L.A. Salcedo, 1 Apr 2009 1:33 PM EST
Transverse myelitis - Spinal cord infarct
Robert C Bucelli, Barnes Jewish, 1 Apr 2009 1:33 PM EST
Infarct of the spinal cord (anterior cord syndrome) secondary to embolism associated with A fib - Diabetic complications.
D. Kapur, 1 Apr 2009 1:33 PM EST
It would be useful to have results of sensory examination and also to know whether he is pyrexial.
Epidural abcess... [more] - Dissecting aneurysm of the aorta
T M, Hospital de Clinicas UFPR - Brazil, 1 Apr 2009 1:33 PM EST
Ischemic infarction of the cord confined to the gray matter due to dissecting aneurysm of the aorta. - Spinal compression
R L, 1 Apr 2009 1:33 PM EST
Ptobable Dx"
Spinal compression due to metastasis? Multiple Myeloma? Vertebral Osteomyelitis? - ddx
rb schmehl, UNC ED, 1 Apr 2009 1:33 PM EST
anterior cord syndrome < trauma/ spinal contusion, anterior spinal artery spasm; ddx leriche syndrome, ddx neoplastic. i don´t understand though... [more] - anterior spinal artery syndrome
Hudson Mourão Mesquita, Brasilia - Brazil, 1 Apr 2009 1:33 PM EST
anterior spinal artery syndrome - Thromboembolism
Markos Kashiouris, Jonhs Hopkins University/Sinai Hospital of Baltimore, 1 Apr 2009 1:33 PM EST
Thromboembolism to the artery of Adamkiewicz secondary to atrial fibrillation - Cervical epidural abscess
Mitchell Francis, 1 Apr 2009 1:33 PM EST
sounds like an infectious process producing a cervical myelopathy. - epidural abscess
E D Borges, 1 Apr 2009 1:33 PM EST
epidural abscess causing cord compression - Answer
Jeffrey D Petersohn, 1 Apr 2009 1:33 PM EST
Epidural abcess - diagnosis
alejandro saleh, 2 Apr 2009 9:22 AM EST
thoracic aorta diseccans - inter scapular pain
uma alampur, 2 Apr 2009 9:22 AM EST
most likely cervical epidural abcess giving above symptoms (cord involvement) - interscapular pain
Manucher Rokhsar, 2 Apr 2009 9:22 AM EST
ischemic(thromboembolic) transvers myelitis. - Spondylodiscitis
Airton Galarca-da-Silva, Porto Alegre - Brasil, 2 Apr 2009 9:22 AM EST
Spondylodiscitis - Aortic Dissection & Artery of Adamkiwicz
William Elias Shomali, University of Jordan, 2 Apr 2009 9:22 AM EST
The patient had an aortic dissection that lead to occlusion of aratery of Adamkiewicz leading to anterior spinal cord syndrome.... [more] - epidural abscess-pyogenic ?AFB possible
Mel Breite MD, office, 2 Apr 2009 9:22 AM EST
The lab says chronic (where's the alk phos?) - Spinal infarction
Alejandro Millan Mon, Pontevedra- Spain, 2 Apr 2009 9:22 AM EST
Neurological data and auricular fibrilation point to embolism in the spinal artery with spinal infarction. I would recomend an spinal... [more] - Response to case
d chao, md, 2 Apr 2009 9:22 AM EST
epidural abscess with diskitis - epidural abcess
f lacruz, 2 Apr 2009 9:22 AM EST
diabetes, leucocitosis, marked elevation of esr,and crp. pain ,and medullar signs - anterior spinal cord infarction
marc allewaert, belgium, 2 Apr 2009 9:22 AM EST
I think that the natural course of the disease of the patient is more that of a sudden event like... [more] - Tuberculosis?
Hon Liang Tan, Singapore, 2 Apr 2009 9:22 AM EST
Thoracic radiograph will be useful: I will consider Pott's Disease along with the other differential diagnosis offered to date. - EPIDURAL ABSCESS
Alfredo Weltson, HC-FMRP-USP, 2 Apr 2009 9:22 AM EST
This is a case of subacute quadriparesis in a female with diabetes and atrial fibrilation. She doesn`t have a history... [more] - giant cellarteritis
dr mohammed aslam khan, jeddah, 2 Apr 2009 9:22 AM EST
giant cell arteritis of descending aorta leading to cord ischaemia - Response to case
mohammad h baloch, 2 Apr 2009 1:59 PM EST
suspect descending aortic dissection/aneurysm - Response to case
A L Carneiro, MD, Military Hospital - Porto, Portugal, 2 Apr 2009 1:59 PM EST
Not vascular; he has no sensory deficit. Legs worse than arms + localized pain + anemia and signs of chronic... [more] - malignancy related spinal cord compression
Noshaba Shahid, 3 Apr 2009 5:11 PM EST
Points in favour of malignancy are,age of patient, significantly raised inflamatory markers, both acute and chronic and mutiple sites involvment... [more] - Diskitis
Norbert R Vella, Mater Dei Hospital, Malta, 6 Apr 2009 9:14 AM EST
In my opinion, the most likely diagnosis is diskitis at the upper dorsal spine, +/- epidural abscess, causing cord compression... [more] - Giant cell arteritis
Kishore V Shetty, 6 Apr 2009 9:14 AM EST
In the absence of sensory deficit, these may be watershed infarcts in the spinal cord. Anemia, markedly elevated ESR and... [more] - Paraneoplastic syndrome
Ravi P Ruberu, Royal Adelaide Hospital, 6 Apr 2009 9:14 AM EST
Predominant motor involvement with possible bladder atonia and the discription of radiating pain, extensor planter response and absent Deep tendon... [more] - Epidural abscess
Athanasios Gaitatzis, The National Hospital for Neurology & Neurosurgery, 7 Apr 2009 7:54 AM EST
Localised spinal tenderness, leukocytosis, raised inflammatory markers. - Cervical myelopathy
Andrés Díaz, Bogotá Colombia, 14 Apr 2009 10:32 AM EST
compressive myelopathy by epidural abscess or by atlantoaxoid dislocation - spinal epidural abscess
Minhaj ul Haq, 14 Apr 2009 10:32 AM EST
sudden weakness, localized tenderness and signs of inflammation - anterior cord syndrome
Muhammad H. Hasan, 14 Apr 2009 10:32 AM EST
Likely from A.Fib Also ?aortic dissection but his not hypertensive - POTT DISEASE (Due Tuberculosis)
ANGEL VARGAS, 17 Apr 2009 1:45 AM EST
POTT DISEASE (Due Tuberculosis) - case answer
Antoine N Finianos, university of Texas aat Houston, 21 Apr 2009 6:07 PM EST
the patient might have transverse myelitis. - syringomyelia
restituto d malonso, 21 Apr 2009 6:07 PM EST
Cervical cord is involved. Diff Dx is broad. I'll add this to the diff. - Epidural Space Infection
Riduan Abdullah, Kedah Medical Centre, Malaysia, 21 Apr 2009 6:07 PM EST
Weakness of the upper limbs, flaccid paraparesis of the lower limbs with thoracic spine tenderness and evidence of infection (raised... [more] - Interscapular pain
JD Guzman, University Hospital "Doce de Octubre", Madrid, Spain, 27 Apr 2009 4:18 PM EST
Anterior spinal artery infarction: Cardioembolism (atrial fibrilation or endocarditis). Acute phase reactants may be due to urinary tract infection (neurogenic... [more] - interscapular pain
kalidoss ramadoss, coimbatore psg hospital, 30 Apr 2009 8:04 AM EST
possible dissection of aorta - Answer for this specific case
Amanullah Khan Sarangzai, Quetta Pakistan, 25 May 2010 2:48 PM EST
Before reading the labs I thought it could be ant spinal artery thrombosis but after reading the investigations it seems... [more]
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