Case 15: A Man With Rapidly Progressing Leg Weakness

Presenter: Connie Chen, MD Preceptor: Justin McArthur, MBBS, MPH


August 15, 2002

In This Article

History of Present Illness

The patient is a 44-year-old, HIV seropositive man (last CD4 count of 18/mm3) who presented with a 2-week history of lower extremity weakness. Approximately 2 weeks earlier, the patient began to notice that he had difficulty going up stairs and getting up from a chair. This symptom was accompanied by pain in his feet, which had worsened from his baseline paresthesias. He did not note any pain or weakness in his upper extremities. The patient was not able to remember whether his lower extremity weakness was symmetric at onset. Around this time, he also began to suffer fevers every day (uncertain about his precise temperature) and a global headache that did not worsen or improve when he changed his head position.

One week after the onset of these symptoms, he also noted "tightness" around his lower back. He began to feel "sharp, shooting" pain to each hip, right side worse than left, and bilateral foot numbness that had increased from his baseline. He reported difficulty with voiding urine and possibly with defecation. Over the course of that second week, walking became progressively more difficult with his worsening lower extremity weakness.

A week and a half after the onset of his symptoms, he sought medical attention at an outside hospital. At this time, the patient reported that he could not feel his bowel movements and his gait had become even worse. His headaches had not abated; they were global, waxing and waning, but not related to position. Fevers as high as 102°F were recorded during this hospital admission.

Lumbar puncture: Cerebrospinal fluid (CSF) opening pressure was not reported; 23 white blood cells (WBCs)/mcL (56% polymorphonuclear cells [PMNs]); 4 red blood cells (RBCs)/mcL; protein: 63 mg/dL; glucose: 52 mg/dL (serum glucose: 116 mg/dL).

MRI lumbar spine with/without gadolinium (Figure 1): minimal disk at L 4/5; possible thickening of cauda equina.

Figure 1.

MRI of the lumbar spine.

Serology: negative for Toxoplasma gondii, Cryptococcus neoformans, and Histoplasma capsulatum and negative rapid plasma reagin test for Treponema pallidum.

At this point, the patient was transferred to Johns Hopkins Hospital (JHH) for further evaluation.


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