Friday, February 8, 2008

Slowly developing Spastic paraparesis case

54 year old man who has not seen a doctor in nine years. Then he began having trouble getting on a bus. He developed a limp 3-5 years prior to presentation, could not run or walk. He dragged his feet and tripped. Past history in unremarkable, he has no meds or allergies, his mother walks with a cane for unknown reasons, and his father had CA liver. He does not smoke or drink, lives alone, never married, denies homosexuality or HIV risk factors. Exam shows good strength throughout, with increased tone in the legs more than the arms. He has impaired VS and PS and temperature sensation in his lower extremities to his knees. He has a wide based spastic gait. Reflexes were brisk with bilateral Hoffmann's and Babinski's signs.

Comment-- this on the surface seems an HSP for which Adams and Victor's Neurology says there are 23 + mutations that can account for this. However, the most common is the SPG4 locus at 2p21-p24. HTLV 1-2 were NR. MRI of whole neuraxis was negative. Other eval is pending. What is the differential?

Notes about HSP (several articles/editorial in Arch Neurol June 2004). Age of onset is highly variable, associations in some kindreds include hearing loss, pes cavus, persistent vomiting due to hiatal hernia, delayed BAEP I-III, thinniong of the corpus callosum, and atrophy of vermis of the cerebellum. A few patients were mentally retarded.

HSP (any of 23 mutations)
fluorosis
HIV
HTLV I-II (ruled out)
MS (negative MRI)
Other TM (transverse myelitis) NMO, SLE, others

Any other thoughts?