Case PresentationTetraparese FlaccidBy: Dian Isti Angraini, S.Ked.Supervisor: Dr. H. A. R. Toyo, Sp.S (K)

Department of Neurology RSMH PalembangFaculty of Medicine University of Sriwijaya

IDENTIFICATIONMr. 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.

ANAMNESIS 8 years before admitted, the 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 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.

ANAMNESISThere 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 ExaminationGeneral StatusSense : compos mentis (GCS=E4M6V5)Nutritive: enoughTemperature: 36,8CPulse: 90 x/minuteRespiratory rate : 20 x/minuteBlood Pressure : 130/80 mmHg

Physical ExaminationGeneral StatusHeart : HR: 90 x/minute, murmur (-), gallop (-)Lung: vesiculer (+) normal, ronchi (-), wheezing(-)Liver : not palpableSpleen: not palpableExtremity : refer to neurological status

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

Physical Examination

Motor Function ArmLegRight Left Right Left MovementlesslesslesslessPower4-54-544Tonic Clonic--Physiological R. Pathological R.HT (+)HT(+)--

Physical ExaminationTropic: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 ExaminationSensory function : No abnormalityVegetative function : No abnormality Higher nervous function : No abnormalityAbnormal Movement : No abnormality Gait, Balance & Postural coordination : (-) Meningeal excitation : None

Laboratory HAEMATOLOGYHemoglobin: 9,9 g/dLED: 55 mm/jamLeucocyt : 9.600/mm3Diff Count: 0/6/2/72/17/3Thrombocyt: 444.000/mm3Haematocrit: 32 vol%

LaboratoryBSS: 134 mg/dl Total cholesterol: 247 mg/dlHDL cholesterol: 60 mg/dlLDL cholesterol: 116 mg/dlTriglyceride : 125 mg/dlUric Acid : 8,4 mg/dlUreum : 30 mg/dlCreatinin : 0,8 mg/dl

LaboratoryTotal protein: 9,2 mg/dlAlbumin: 3,4 g /dlGlobulin: 5,8 g/dlSodium: 132 mmol/lPotassium: 3,3 mmol/lCalsium: 2,2 mmol/l BTA I,II: negatif

Additional ExaminationECG:Ischemic anteroseptal + RBBB incomplete

Topical Diagnosis : The possibility on cornu anterior can be rejected.

Topical Diagnosis The possibility on motor end plate can be rejected.

Topical Diagnosis The possibility on radiks anterior can be rejected.

Topical DiagnosisThe possibility of muscular lession cannot be rejected.

Etiological DiagnosisThe possibility of myopathy can be rejected.

1. MyopathySymptoms on the patient were:Symptom:Periodic weakness or paralysed on all of the limbProgressive body weakness in short time, commonly on rest or hyperactivityCorticosteroid history in long timeWeakness on all of the limb in stages and getting worse.Slowly weakness about 11 years.Corticosteroid history in long time (-)

Etiological DiagnosisThe possibility of myocytis can be rejected.

Etiological DiagnosisThe possibility of SMA type III can be rejected.

3. . Spinal Muscular Atrophy type III Symptoms on the patient were:Symptom:Onset : 2-17 years oldCant stand up without assisstTremor (+)Onset of weakness: 7 years oldStill can stand up and walking in the first time of symptomTremor (-)

Etiological Diagnosis

4. Becker Muscular DystrophySymptoms 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 musclesWhen stand up, he must hold his knee first after that hold his thigh,

Etiological DiagnosisThe possibility of Becker Muscular Dystrophy can be rejected.

4. Becker Muscular DystrophySymptoms on the patient were:Symptom:

Contracture on joint (+)Onset: 11-21 years oldIncrease of CPK value 20-100x 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 oldIncrease of CPK value 20 x

Etiological Diagnosis

5. Duchene Muscular DystrophySymptoms 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 musclesWhen stand up, he must hold his knee first after that hold his thigh,

Etiological DiagnosisThe possibility of Duchene Muscular Dystrophy cannot be rejected.

5. Duchene Muscular DystrophySymptoms on the patient were:Symptom:

Contracture on joint (+)Onset: 3-7 years oldIncrease of CPK value 20-100x 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 oldIncrease of CPK value 20 x

DIAGNOSISClinical Diagnosis :Tetraparese Spastik Topical Diagnosis :

Etiological Diagnosis :

MANAGEMENTDiet NB TKTPVitamin B19 3x1 tablet / dayNeurobion 500 mg 3x1 tab

EXAMINATION PLANNINGRontgen thoraxEMGMuscle biopsyRo columna vertebralis cervical-lumbosacral AP-Lat

PROGNOSISQuo ad vitam : dubia ad malam

Quo ad functionam : malam

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