Case Presentation

Tetraparese Flaccid
By: Dian Isti Angraini, S.Ked. Supervisor: Dr. H. A. R. Toyo, Sp.S (K)

Department of Neurology RSMH Palembang Faculty of Medicine University of Sriwijaya

IDENTIFICATION

Mr. T/42 years old/male/ Moslem/stay outside town in /Oct 2nd 2008.

ANAMNESIS
The patient was hospitalized in neurology ward of RSMH Palembang because of the difficulty to walk that caused by the weakness of both lower and upper limb which happened slowly. 11 years before admitted, the upper and lower limb muscles was very well developed look like an athlete. No muscle weakness and disturbances of walking. Mixtie and defecation normal.

patient had fever, high, fluctuated, 1 week until 1 month, no seizure, no decrease of consiousness. The fluctuated fever happened about 1 year. The patient already have weakness on the left lower limb, the patient can walk on the forward part of the foot with the heels off the ground . No sensibility disturbances and waddling. Mixtie and defecation normal.

ANAMNESIS 8 years before admitted, the

ANAMNESIS
7 years before admitted, the patient had difficulty to stand up. The weakness on left lower limb become more seriously. He also felt weakness on right lower limb. When the patient want to stand up, he must hold his knee first after that hold his thigh, climb to hold his hip and stand up. He used to get fall down after take awalk few steps. It was difficult for him to have a balance gait when he stand up. The upper and lower limbs muscles was going to be smaller. There were no disturbances of sensibility, mixtie and defecation.

ANAMNESIS
5 years before admitted, the patient couldnt stand up again, he could seated and felt weakness on both of upper limb, he still could spoon of on behalf to his mouth with the elbow based on his thigh. Sometimes he felt twitch and become numb (paresthesi) on both of the lower limb and the upper limb. There were no disturbances of sensibility, mixtie and defecation.

ANAMNESIS
1,5 years before admitted, the patient couldnt seated anymore, the backbone become curve if the patient in seated position. There were no disturbances of sensibility, mixtie and defecation.

ANAMNESIS
There were no history of febrile seizure, truncus injury, or truncus disease. There are family history in his old brother, young brother and 2 of his uncles. This illness was the first time for him.

Physical Examination
General Status
Sense Nutritive Temperature Pulse Respiratory rate Blood Pressure : compos mentis (GCS=E4M6V5) : enough : 36,8C : 90 x/minute : 20 x/minute : 130/80 mmHg

Physical Examination
General Status
Heart Lung Liver Spleen Extremity : HR: 90 x/minute, murmur (-), gallop (-) : vesiculer (+) normal, ronchi (-), wheezing(-) : not palpable : not palpable : refer to neurological status

Physical Examination
Neurological Status
Nn. Craniales: N. Accesorius : there is limitedness to raise the shoulder.

Physical Examination
Motor Function Right Movement Power Tonic Clonic Physiological R. Pathological R.
less

Arm Left
less

Leg Right
less

Left
less

4-5

4-5

4 -

4 -

HT (+)

HT(+)

Physical Examination
Tropic: There are atrophy on m. sternocleidomastoideus, m. trapezius, upper arm muscles, hand muscles, thoracalis muscles, hip muscles, upper leg muscles and foot muscles. Contracture: on both of leg. Columna Vertebralis : scoliosis (+)

Physical Examination
Sensory function Vegetative function Higher nervous function Abnormal Movement Postural coordination Meningeal excitation : No abnormality : No abnormality : No abnormality : No abnormality Gait, Balance & : (-) : None

Laboratory
HAEMATOLOGY Hemoglobin LED Leucocyt Diff Count Thrombocyt Haematocrit

: 9,9 g/d : 55 mm/jam : 9.600/mm3 : 0/6/2/72/17/3 : 444.000/mm3 : 32 vol%

Laboratory
BSS Total cholesterol HDL cholesterol LDL cholesterol Triglyceride Uric Acid Ureum Creatinin : 134 mg/dl : 247 mg/dl : 60 mg/dl : 116 mg/dl : 125 mg/dl : 8,4 mg/dl : 30 mg/dl : 0,8 mg/dl

Laboratory
Total protein Albumin Globulin Sodium Potassium Calsium BTA I,II : 9,2 mg/dl : 3,4 g /dl : 5,8 g/dl : 132 mmol/l : 3,3 mmol/l : 2,2 mmol/l : negatif

Additional Examination
ECG:
Ischemic anteroseptal + RBBB incomplete

1. Cornu anterior

Topical Diagnosis :

Symptoms on the patient were:

Symptom: Muscles weakness, first weakness on hands then shoulder muscles and upper arm. Fasciculation (+) Sensory disturbances (+) Injury history (+)

Weakness begin from leg muscles Fasciculation (-) Sensory disturbances (-) Injury history (-)

The possibility on cornu anterior can be rejected.

2. Motor End Plate

Symptom:

Topical Diagnosis

Symptoms on the patient were:

Weakness on both of arm and refer to hand muscles, ocular, abdominal and thoracalis muscles that happened after rest. Diplopia (+) on the beginning, then become bulbair paralysed and limb paralysed.

Weakness on both of leg and refer to arms that happened slowly about 11. Diplopia (-)

The possibility on motor end plate can be rejected.

Topical Diagnosis
3. Radiks Anterior
Symptom:

Symptoms on the patient were:

Weakness on limb muscles, developed little by little. Sensory disturbances (-) Subacute and chronic

Weakness on limb muscles that happened slowly Sensory disturbances (-) Weakness happened slowly about 11 years

The possibility on radiks anterior can be rejected.

4. Muscular

Topical Diagnosis Symptoms on the patient were:

Pseudohypertrophy of muscle (+) Flaccid paralyse on all of the limb Family history (+) High CPK value

Symptom: Pseudohypertrophy of muscle Flaccid paralyse on all of the limb Family history (+) High CPK value

The possibility of muscular lession cannot be rejected.

Etiological Diagnosis
1. Myopathy Symptoms on the patient were:

Symptom: Periodic weakness or paralysed on all of the limb Progressive body weakness in short time, commonly on rest or hyperactivity Corticosteroid history in long time

Weakness on all of the limb in stages and getting worse. Slowly weakness about 11 years. Corticosteroid history in long time (-)

The possibility of myopathy can be rejected.

Etiological Diagnosis
2. Miocytis Symptoms on the patient were:

Symptom: Fever history (+) There are weakness and muscle pain. LMN paralyse on all of the limb, motoric, one time and continously.

Fever history (+) Muscle pain (-) Riwayat demam ada Tidak ada nyeri otot Slowly LMN paralyse and getting worse

The possibility of myocytis can be rejected.

Etiological Diagnosis
3. . Spinal Muscular Atrophy Symptoms on the patient were:

type III Symptom: Onset : 2-17 years old Cant stand up without assisst Tremor (+) Onset of weakness: 7 years old Still can stand up and walking in the first time of symptom Tremor (-)

The possibility of SMA type III can be rejected.

Etiological Diagnosis
4. Becker Muscular Dystrophy Symptoms on the patient were:

Symptom: Pseudohipertrofi (+) Weakness started on Pseudohipertrofi (+) proximal muscles like Weakness started on proximal hip muscles, upper leg muscles like hip muscles, muscles, shoulder and upper leg muscles, shoulder upper arm muscles and upper arm muscles. When stand up, he Difficult and weakness on must hold his knee walking, easy to fall and loss first after that hold of balance.

his thigh,

Etiological Diagnosis
4. Becker Muscular Dystrophy Symptoms on the patient were:

Symptom: Contracture on joint (+) Onset: 11-21 years old Increase of CPK value 20100x

climb to hold his hip and stand up, difficult for him to have a balance gait. Contracture (+) knee joint and ankle joint. Onset : 7 years old Increase of CPK value 20 x

The possibility of Becker Muscular Dystrophy can be rejected.

Etiological Diagnosis
5. Duchene Muscular Dystrophy Symptoms on the patient were:

Symptom: Pseudohipertrofi (+) Weakness started on proximal muscles like hip muscles, upper leg muscles, shoulder and upper arm muscles. Difficult and weakness on walking, easy to fall and loss of balance.

Pseudohipertrofi (+) Weakness started on proximal muscles like hip muscles, upper leg muscles, shoulder and upper arm muscles When stand up, he must hold his knee first after that hold his thigh,

Etiological Diagnosis
5. Duchene Muscular Dystrophy Symptoms on the patient were:

Symptom: Contracture on joint (+) Onset: 3-7 years old Increase of CPK value 20100x

climb to hold his hip and stand up, difficult for him to have a balance gait. Contracture (+) knee joint and ankle joint. Onset : 3-4 years old Increase of CPK value 20 x

The possibility of Duchene Muscular Dystrophy cannot be rejected.

DIAGNOSIS
Clinical Diagnosis :
Tetraparese Spastik

Topical Diagnosis :

Etiological Diagnosis :

MANAGEMENT
Diet NB TKTP Vitamin B19 3x1 tablet / day Neurobion 500 mg 3x1 tab

EXAMINATION PLANNING
Rontgen thorax EMG Muscle biopsy Ro columna vertebralis cervical-lumbosacral AP-Lat

PROGNOSIS
Quo ad vitam : dubia ad malam
Quo ad functionam : malam