PakMediNet Discussion Forum : Medicine : Paraplegia as a complication of Meningococcal meningitis
Paraplegia as a complication of Meningococcal meningitis
Assalam o alaikum all
Can any body inform me that is paraplegia a common or rare complication of meningococcal meningitis
What is your experience and do you know of any case reported in literature from Pakistan...
[Edited by drrathore on 17-08-2006 at 06:26 AM GMT]
Posted by: drrathorePosts: 428 :: 17-08-2006 :: | Reply to this Message
Re: Paraplegia as a complication of Meningococcal meningitisI never heard of such complication. Even in books and medical reference softwares, it is not mentioned. If this case has no other cause of paraplegia, then this case should be reported.
Posted by: yasirPosts: 90 :: 22-08-2006 :: | Reply to this Message
Paraplegia as a complication of Meningococcal meningitis
I am attaching one case report. There are other reports if you search pubmed.Meningiococcal meingitis is a fulminant form of meningitis and if not treated promptly can cause deficits at different levels of the central neural axis.
Bal S, Kurtulmus S, Kocyigit H, Gurgan A. Related Articles, Links
A case with cauda equina syndrome due to bacterial meningitis of anterior sacral meningocele.
Spine. 2004 Jul 15;29(14):E298-9.
PMID: 15247591 [PubMed - indexed for MEDLINE]
Posted by: NizamPosts: 82 :: 22-08-2006 :: | Reply to this Message
Paraplegia as a complication of Meningococcal meningitis
Thank you for replying to my query..let me add some more details and may be it will generate some more discussion
18 years old boy was admitted in a drowsy state with one day h/o high grade fever and neck rigidity. LP revealed turbid colored CSF with gram negative intra cellular diploccci on Gram staining. He responded well to 3 rd Gen cephalosporins and Bezyl penicillin and conciousness improved over the next 4 days but he had complete flaccid paraplegia with impairment of pin prick and temperature below T 11 along with double incontinence. When he was discharged his father kept on taking him to different medical specialists and then neurophysicians also. he underwent 03 MRI of Dorsolumber spine and 03 CT scan Brain and EEG over the next 01 month.... All were normal but he was labelled as a case of Transverse Myelitis and then Carries Spine.... Actually he landed with us a month back in pretty bad shape with three grade 4 pressure and malnutrition and anemia with rective depression... we stopped his ATT ... At present we are managing his ulcers and associated problems and he has shown remarkable improvement in terms of improved Hb and Albumin,well healing pressure ulcers and alleviation of mood although no improvement in motor fuction of lower limb has been observed
The reson i put this case on this forum was to have feed back from my other colleagues about this rare complication.... Beacuse "THE EYE CANNOT SEE WHAT THE MIND DOESNT KNOW"
and if we dont share this knowledge we may be doing more harm to the patient by ordering expensive and USELESS investigations just for the sake of it and to keep our practise alive...
I still would like to hear from my fellow doctors in neurology about this case
PS: the proposed mechanism of paraplegia secondary to meningitis is cord infarction or specifically Ant. Spinal Artery Thrombosis... but there was no objective evidence of cord infarct on MRI and this makes it an interesting case
[Edited by drrathore on 23-08-2006 at 05:55 AM GMT]
[Edited by drrathore on 23-08-2006 at 05:56 AM GMT]
Posted by: drrathorePosts: 428 :: 23-08-2006 :: | Reply to this Message
Re: Paraplegia as a complication of Meningococcal meningitis
This is an interesting case as the cause of flaccid paraplegia with spinothalamic signs with a normal MRI. Have you considered the possibility of Multiple sclerosis (primary progressive type)? I think this patient needs consultant neurologist opinion and I hope Dr. Nizam will assist in this case. We do want to see the MRI in someway if facilities are available.
Thank you
Posted by: yasirPosts: 90 :: 23-08-2006 :: | Reply to this Message
Re: Paraplegia as a complication of Meningococcal meningitis
I need to know more information. What about his bowel and bladder functions? Is there a sensory level on pin-prock examination? Is there a sensory deficit in a dermatomal distribution? What is his anal tone? Can you grade his weakness and describe strength in the individual muscles? Are muscle stretch reflexes exaggerated, diminished or normal? What about his plantar reflexes (flexor or extensor)? Was the MRI done with gadolinium specifically looking at the nerve roots for polyradiculutis or a paraspinal abscess?
I would not consider multiple sclerosis in the differential diagnosis as it gives long tract signs with increased tone and not a flaccid paraplegia. I look forward to the above details.
Nizam
[Edited by Nizam on 23-08-2006 at 11:33 PM GMT]
Posted by: NizamPosts: 82 :: 23-08-2006 :: | Reply to this Message
Re: Paraplegia as a complication of Meningococcal meningitis
Correction: I meant to say that multiple sclerosis does not cause flaccid parapleagia. It can cause spastic paraplegia.
Nizam
[Edited by Nizam on 23-08-2006 at 11:33 PM GMT]
[Edited by Nizam on 23-08-2006 at 11:37 PM GMT]
Posted by: NizamPosts: 82 :: 23-08-2006 :: | Reply to this Message
Re: Paraplegia as a complication of Meningococcal meningitis
Sir, you are right that MS doesnt causes flaccid paralysis, but what could else be the cause of spastic paraplegia with normal MRI and CT. The signs that are mentioned by drrathore are suggestive of spastic paraparesis with spinothalamic tract and bladder / bowel involvement (at T11). I wonder what else could be the cause if upper limbs are normal and brain stem scan is also normal.
[Edited by yasir on 24-08-2006 at 08:01 AM GMT]
Posted by: yasirPosts: 90 :: 24-08-2006 :: | Reply to this Message
Re: Paraplegia as a complication of Meningococcal meningitisAs Dr Rathore indicated in the history this patient had Flaccid (not spastic) paraplegia with urinary and bowel incontinence and a sensory level at T11. The most likely differential diagnosis would include a paraspinal abscess. Cauda equina syndrome can not be ruled out. Polyradiculits secondary to meningiococcal meningitis is yet another possibility. If MRI was without gadolinium (contrast)these diagnosis can be easily missed. Based on the history of flaccid paralysis, transverse myelitis is very unlikely. An EMG in expert hands will be useful to rule out nerve root involvement.
Posted by: NizamPosts: 82 :: 24-08-2006 :: | Reply to this Message
Re: Paraplegia as a complication of Meningococcal meningitis
Thoracic myelopathy complicating acute meningococcal meningitis: MRI findings.
Am J Med Sci. 2002; 323(5):263-5 (ISSN: 0002-9629)
Bhojo AK; Akhter N; Bakshi R; Wasay M
Department of Neurology, The Aga Khan University, Karachi, Pakistan.
Spinal cord dysfunction is a rare complication of Neisseria meningitidis (meningococcal) meningitis. We report a 17-year-old patient who had a 3-day history of fever, headache and vomiting, agitation, and unresponsiveness. Cerebrospinal fluid showed a marked polymorphonuclear pleocytosis. Latex particle agglutination was positive for meningococci. The patient was given intravenous antibiotics and intravenous dexamethasone. Over the next 4 days, he developed weakness of the lower extremities, with areflexia and extensor plantar responses. MRI revealed contiguous hyperintensities on T2-weighted images involving the thoracic spinal cord from T4 to T9 and 4 brain abscesses. Five months later, he recovered brain function, but the paraparesis remained. This case illustrates that myelopathy may complicate acute meningococcal meningitis, possibly due to a vasculitis, stroke, autoimmune myelopathy, or direct infection of the spinal cord. Patients with myelopathy associated with acute meningitis should receive spinal MRI. In addition, meningitis should be considered in patients presenting with acute myelopathy.
Posted by: depressedPosts: 8 :: 24-08-2006 :: | Reply to this Message
Paraplegia as a complication of Meningococcal meningitis
I would like to thank all my colleagues who participated in this discussion.Some more clarifications are as under
1.Paraplegia as a complication of pyogenic meningitis has been documented in literature but its rare.... so i presented it on this forum
2. This boy had and is still having flaccid paraplegia with 0/5 muscle power in lower limbs, areflexia, equivocal plantars and patolous anal tone.
3. As per his narrative and medical record... at the onsent of illness i.e on 2 nd April he had complete sensory loss to pinprick and touch below T 10.... This has improved to sensory impairment but there is a definite level
4. MRI were performed without contrast.... but still i would not bet on a paraspinal absess
5. EMG/NCS were performed in the 10 th week post illness and was suggestive of Acute Inflammatory Demyelinating polyneuropathy( But i am not convinced because of sphincter and sensory system involvement..... i have asked for a repeat EMG/ NCS)
6. Sadly he has been reviewed by great names in neurlogy both in Lahore and Rwp but they always considered TM and Carries spine and he underwent 03 CT Scan brains ( which were definitely not indicated , because of the flaccid nature of paraplegia) and EEG Brain ( which i again fail to understand). It was in Rwp that a neurophysician suspected Ant. Spinal Artey Thrombosis as a complication and advises Spinal Angiogram which was not done.
7. And to add a further depressing touch to the case... the patient or his family were never counsellled about the disease and every place they visited ended in spending thousands of rupees on investigations that were already available.
8. Any body interested in reviewing the MRI is most welcome
So THE MORAL OF THE CASE ( as i have understood)
1. If you are not sure of the diagnosis ,please consult a specialist colleague of that field
2. Always explain the patient and family whats wrong ? Dont take them as guine pigs
3. Last but not the least DONT ADVICE USELESS INVESTIGATIONS again and gain .... just to fill your pocket
[Edited by drrathore on 27-08-2006 at 07:34 AM GMT]
Posted by: drrathorePosts: 428 :: 27-08-2006 :: | Reply to this Message