48 YEAR OLD MALE WITH BURNING SENSATION IN BOTH LOWER LIMBS

UNIT 6

48 year old male patient from Devarakonda, farmer in cotton field and also works as daily wage worker, came with the chief complaints of 

1.Burning sensation of both lower limbs since

8months

2. Slippage of slippers since 8months

3. Hypo pigmented skin lesions on both lower limbs since 8months.

HOPI:

Patient was apparently asymptomatic 8months ago when he developed difficulty in holding slippers ,gradually progressive and worsened over last 2months so much so that he stopped wearing slippers,No difficulty in getting up from squatting position,mixing food ,buttoning the shirt,combing hair,no difficult in lifting the head off the pillows,rolling over the bed,no difficulty in breathing or diurnal variation of the weakness

Complaints of burning sensation of both lower limbs gradually progressive since 8 months and has worsened over the last 2months associated with numbness,decreased sleep because of burning sensation,Not associated with tingling or paraesthesias.Patient is able to feel clothes and warm water and cold water during bath.

Complaints of severe pins and needle sensations over outer aspect of leg and patient noticed that when he taps his leg just below the knee on the outer aspect he feels a shock like sensation and pain radiating down on the outer aspect of both legs.No h/o any excess crossed leg sitting posture

No h/o any sensation of walking on cotton wool,no complaints of neck pain, back pain, band like sensation,

No h/o any loss of consciousnesses or altered sensorium,seizures,head injury or trauma to the leg,speech disturbances,no bowel or bladder incontinence,memory disturbances

Sleep disturbances+

No h/o any delusions,hallucinations, emotional disturbances

No h/o any altered no difficulty in sensing smell,vision ,hearing

No tinnitus ,vertigo taste

No difficulty in lifting shoulder,deviation of mouth

No h/o any spillage of food while taking it to the mouth or clumsiness of hands

Unsteadiness while walking and closing eyes+

No h/o any palpitations,sweating,able to feel bladders fullness,initiate micturition,feel the passage of urine,able to completely evacuate the bladder

No h/o Fever ,vomitings,neck pain,trauma,lifting heavy objects on head /back,headache,vomiting,diarrhoea,

Incidentally found to be hepatitis B positive 20days back

Complaints of hypo pigmented skin lesions over both lower limbs since 6months and reduced sensations over the skin lesions.

Complaints of weight loss of 7kgs over the last 4-5 months.

Complaints of transient pain in right upper abdomen and was treated conservatively for gall bladder stones 10days ago.

PAST HISTORY:

Not a K/C/O DM,HTN,CKD,epilepsy,asthma,TB

No h/o similar complaints in the past

PERSONAL HISTORY:

48 Yr old male studied upto 10th class and stopped further studies because of financial issues and started working as a farmer.

Married at the age of 15

Has 1Son 2daughters all of them married

Alcoholic since 25years and stopped one year back

Non smoker

Mixed diet

Regular bowel and bladder habits

Disturbed sleep  since 2months

Family history:

No significant family history.

Treatment history :

tenofovir alfenamide since 20days

Pregabalin

General examination:

Patient is conscious,coherent ,cooperative

Thin built

 No signs of pallor icterus cyanosis clubbing lymphadenopathy and edema.

Vitals:

Afebrile

PR:86bpm ,Regular ,normal volume,character,No RR delay,RF delay

BP: 110/80mmhg measured in upper limb in sitting position

RR: 16/min regular ,abdominothoracic

SpO2- 99% on RA

SYSTEMIC EXAMINATION:

CNS:

Higher mental functions:intact

Cranial nerve examination:

OLFACTORY NERVE- 

NORMAL

OPTIC NERVE-

  Visual acuity.  Cf6 both eyes

  Pupils:B/L Normal size,Direct and indirect reflexes +

  Accomodation reflex+

CRANIAL NERVE 3,4,6-

    No ptosis,EOM normal

TRIGEMINAL:

   Chewing normal

   Facial sensations normal

FACIAL:

   Frowning normal

   No deviation of mouth

VESTUBULO-COCHLEAR NERVE:

   Rinnes- AC>BC both ears

   Webers-no lateralisation 

GLOSSOPHARYNGEAL NERVE- 

   Uvula central

 VAGUS NERVE-

   Shrugging of shoulders normal

HYPOGLOSSAL NERVE

   Normal tongue movements

MOTOR

Attitude :Sitting on the couch with hands placed on the sides and bilateral foot dangling downwards 

Bulk:                           R.                 L

UL-Arm.                 22cms        22cms

     -Forearm.         21cms         21cms

LL. -Arm.               33.5cms       33cms

       -Forearm.       24.5cms       24.5cms

   

Tone                     Normal.        Normal

Power:

 1.neck flexion.         Normal        

 2.Neck extension   Normal          

                                   R.                  L

Upper limb.  All:      5/5.               5/5

 3.Supraspinatus.  

4.Deltoid

5.infraspinatous

6.Rhomboids

7.Serratus anterior

8.Pectoralis major

9.Lattismus dorsi

10.Biceps

11.Brachioradialis

12.Triceps

13.Hand muscles 

Trunk muscles :Normal.        

Lower limbs:

1.Iliopsoas.                    5/5.              5/5

2.adductor femoris      5/5.              5/5

3.Gluteus medius.         5/5.             5/5

4.Gluteus maximus       5/5.             5/5

5.Hamstrings.                 5/5.            5/5

6.Quadriceps femoris.   5/5.           5/5

7.Tibialis anterior.           0/5.           0/5

8.Tibialis posterior.         5/5.           5/5

9.peronei                          0/5.           0/5

10.FDL.                             5/5.           5/5

11.EDL.                             0/5.            0/5            

12.EHL.                             0/5.            0/5. 

13.EDB.                             0/5.            0/5

Reflexes:

Superficial reflexes:

Corneal+

Conjunctival+

Abdominal

Plantar.                            Mute.          Mute

DTRs:

Biceps.                             2+.               2+

Triceps.                            2+.               2+

Supinator.                        2+.               1+

Knee.                                2+.               2+

Ankle.                             Absent.       Absent

No primitive reflexes

No involuntary movements

Gait - High stepping gait/ Equine gait

Link for the video 🔗

https://youtube.com/shorts/cz-kWMOHW4k?feature=share3

SENSORY:

Crude touch

   Upper limbs -normal bilaterally 

   Trunk-normal

   Lower limbs-reduced in the lower 1/3rd of anterolateral leg

    Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally

Pain:

     Upper limbs -normal bilaterally 

     Trunk-normal

     Lower limbs-reduced in the lower 2/3 rd of anterolateral leg

      Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally

Vibration: Reduced distally 

Joint position                  Absent  Bilaterally 

Fine touch :normal in all limbs ,trunk except for reduced fine touch in lower 3rd of anterolateral leg,dorsum of foot

Absent fine touch in the web of 1st and 2nd toe in right lower limb and reduced in left lower limb

Rombergs -Positive (swaying with eyes closed)

Stereognosis: normal

CEREBELLAR SIGNS:

No titubation

Finger nose test, Finger finger test-normal

Heel knee test -normal

No rebound phenomenon

No dysdiadakokinesia

MENINGES:

No signs of meningeal irritation

PERIPHERAL NERVES:

-Thickened nerves: Bilateral common peroneal palpable

Bilateral sural nerve palpable

Tibial nerve-not palpable on both sides

LOCAL EXAMINATION-

Multiple marked hypopigmented and hypoanesthetic patches seen over bilateral foot

Asymmetrical 

Surface:Dry

surrounding erythema :absent

central healing:No

elevated margin:present

Clarity of margin:good

CVS:

Apex 5th ICS,0.5 inch medial to mid clavicular line

Heart sound normal 

No murmurs

RS:

Tracheal central,

Chest elliptical bilaterally symmetrical

Chest movements normal

Normal vesicular breath sounds

P/A :Soft,Non tender

No organomegaly 

Final diagnosis:Chronic peripheral neuropathy with Mononeuritis multiplex pattern involving bilateral superficial peroneal,deep peroneal,Sural nerves in both sensory and motor component with both small and Large fibre involvement 

DD1:Most probably secondary to Hansen's (Late stage as large fibres are also involved)

In favour of :?Borderline Tuberculoid leprosy,

Few skin lesions with

Early nerve involvement

Assymetrical nerve thickening

Hypesthesia and myopathy

DD2:L5 radiculopathy

Justification for Not radiculopathy:

1.No radicular pain

2.No spinal tenderness

3.No clear cut dermatomal distribution of sensory loss

DD3:Hepatitis B induced peripheral neuropathy? Polyarteritis nodosa with mononeuritis multiplex

DD4:Vasculitis -PAN,Wegeners

1.Age not in favour

2.Hypopigmented hypoanesthetic patches can’t be justified

3.No h/o any constitutional symptoms,Organ dysfunction 

4.small fibre involvement predominates

DD5:

Diabetes

Not in favour because:

1.In diabetes Small fibre predominates

2.No history of diabetes

DD6:

Lymes disease:No evidence of any eryhema chronicum,Fever,Arthritis

DD7:

Entrapment:Sarcoidosis,Amyloidosis

No other evidence suggestive of these

Further evaluation needed:

1.Slit skin smear from the most hypoanaesthetic macule and skin biopsy

2.Nerve biopsy

3.Nerve conduction study

4.Serology -HIV ,Hepatits B,C

5.HBV viral load,Fibroscan,LFT

6.FBS,PLBS for any impaired glucose tolerance and diabetes

INVESTIGATIONS:

Hb:9.9gm/dl

TLC:7,800

Platelets :2.91

PBS:NC/NC

RBS 80

Urea:32

Creatinine:0.7

Na:141

K:4.1

Cl:102

Total bilirubin 0.37

Direct bilirubin 0.19

AST 16

ALT. 19

ALP. 162

Total protein 5.3

Albumin 3.1

A/G:1.45

CUE:WNL

HBsAG +

HCV-

HIV -

USG abdomen: Normal size and echotexture of liver,cholelithiasis +

ECG-

Nerve conduction study done 8 months ago:

Showing reduced CMAP s in bilateral common Peroneal nerve and reduced SNAP in left sural nerve

Plan for split skin smear and biopsy