A 24-year-old woman comes to the physician with 2 days of progressive leg weakness and paresthesias. Today, she could not void urine. She has no significant medical history, except for an upper respiratory tract infection 2 weeks ago. The patient takes no medications and does not use illicit drugs. Her blood pressure is 110/70 mm Hg and pulse is 80/min. Physical examination shows bilateral lower-extremity weakness, decreased reflexes, and decreased pain sensation up to the level of the umbilicus. Sensations are intact in the dermatomes above the umbilicus. Bladder catheterization shows a volume of 500 mL. Which of the following is the best next step in management of this patient?

Question

A 24-year-old woman comes to the physician with 2 days of progressive leg weakness and paresthesias.  Today, she could not void urine.  She has no significant medical history, except for an upper respiratory tract infection 2 weeks ago.  The patient takes no medications and does not use illicit drugs.  Her blood pressure is 110/70 mm Hg and pulse is 80/min.  Physical examination shows bilateral lower-extremity weakness, decreased reflexes, and decreased pain sensation up to the level of the umbilicus.  Sensations are intact in the dermatomes above the umbilicus.  Bladder catheterization shows a volume of 500 mL.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c009_f0dd_8f63_7111c297128b_MD0005_00 This patient has a rapidly developing myelopathy as evidenced by flaccid paralysis and paresthesias, along with a clearly demarcated sensory level at the umbilicus. Flaccid paralysis and hyporeflexia with a history of upper respiratory infection (URI) may also suggest Guillain-Barré syndrome (GBS). However, a sensory level and bowel/bladder dysfunction after a URI make transverse myelitis (TM) more likely. Flaccid paralysis and hyporeflexia are common in early stages of myelopathy (spinal shock). Guillain-Barré syndrome (GBS) MRI is necessary to diagnose the cause of acute myelopathy. In the absence of overt trauma or history of malignancy, compressive lesions such as tumor, herniated intervertebral disk, and epidural abscess are less likely but must still be ruled out. In addition, MRI will show enhancement of the affected spinal cord regions with gadolinium in TM. Three to five days of high-dose corticosteroids should be given once TM is diagnosed. Empiric steroids may be given if there is high suspicion of compressive myelopathy in the setting of malignancy. (Choice A) MRI provides better definition of neuronal tissue, disk, ligaments, epidural fat, and shape and size of the spinal canal. CT scan is better for detection of bony abnormalities. (Choice B) A lumbar puncture should be performed to identify the cause of noncompressive myelopathy. Cerebrospinal fluid (CSF) analysis may be helpful in differentiating idiopathic from secondary TM. (Choice D) Nerve conduction studies are useful in evaluating peripheral nerve disorders such as GBS or carpal tunnel syndrome. They can differentiate among axonal disease, demyelinating disorders, and conduction defects. They do not provide any definitive diagnostic or prognostic information in myelopathy. (Choice E) Plain x-ray of the vertebrae is indicated only in patients with low back pain without neurologic deficits and who are at high risk of vertebral fractures (eg, trauma, prolonged glucocorticoid use, osteoporosis, age >70). Educational objective: Acute paralysis with the presence of a sensory level or bowel/bladder dysfunction suggests acute myelopathy. These patients should be evaluated immediately with MRI. Steroids should be administered after the diagnosis is established with MRI or empirically if suspicion for compressive myelopathy is high, as in malignancy. References: Myelopathy. (http://www.ncbi.nlm.nih.gov/pubmed/18477657) Acute inflammatory myelopathies. (http://www.ncbi.nlm.nih.gov/pubmed/24507538)

A 24-Year-Old Woman Comes to the Physician with 2 Days