February 2018

A 65-Year-Old Man With Rapidly Progressive Quadriparesis

History & Exam

History
 
A 65-year-old male presents with a rapidly progressive history of triceps, hands and lower extremity weakness. His hands have progressively lost strength and he has been non-ambulatory over the past day. He was recently admitted with fevers and a diagnosis of pneumonia and bacteremia. His remote history is notable for an esophageal achalasia, esophageal perforation, esophagectomy and gastric pull-up surgery. 
 
Exam
 
Afebrile and normotensive. Tachycardia HR 100.  Malnourished.
No scars on anterior or posterior neck. Healed scar over abdomen and lower chest.  
Positive sagittal balance with cervical kyphosis. Neck and back are not tender. Reduced range of motion neck.
Negative Spurling’s sign. Positive Lhermitte's sign
Cranial nerves II-XII are intact
DTRs – 3+ upper extremities, 3+ lower extremities
Strength- 5/5 Deltoid and biceps; 4/5 Triceps; 3/5 wrist extensors/flexors; 3/5 hand intrinsics
4+/5 bilateral lower extremities
+ Clonus bilateral lower extremities, Positive Hoffman’s sign bilateral, Positive bilateral Babinski Sign.
Slightly decreased pinprick sensation from upper chest down
Spastic gait

Upright Radiographs

Upright Radiographs

Magnetic Resonance Imaging

Magnetic Resonance Imaging

Magnetic Resonance Imaging

Magnetic Resonance Imaging

Questions

Your answers will be added to those already obtained and tabulated at the end of the month.

References

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