A Case of Acute Flaccid Paralysis: An Uncommon Presentation of a Common Disease

Abstract

An eleven year old girl from the periphery of Kathmandu valley presented to our hospital with the history of highgrade fever since the past twenty days, gradually progressive weakness of lower limbs since the last eight days and inability to stand or walk along with loss of bowel and bladder control for two days. There was no history of trauma, altered level of consciousness, skin or mucosal bleeds or any joint symptoms. She received some medications from the local heath post, details of which were not known. There was no signifi cant past medical history and no known TB contacts. She was third of the six children in the family and was not immunized against any of the vaccine preventable diseases On examination she was conscious, febrile, sick looking, pale and had generalized bony tenderness. Vitals were stable. Cranial nerves and sensations were intact. She had complete fl accid paralysis of the lower limbs with diminished but preserved knee jerks and bilateral up going planters. There was doubtful neck stiffness and no papilloedema. Other systemic examinations were normal.Initial investigations showed normal total and differential counts. She had low Hematocrit (24 %) and the Platelet count was (82,000/cu mm). Cerebrospinal fl uid analysis showed WBC 35 with 45% Polymorphs, Protein of 635 mg/dl and Sugar 44 mg/dl. Blood Sugar, Electrolytes, Creatinine, Chest and Spinal X-rays were all normal.The differential diagnoses on admission were partially treated meningitis versus tubercular meningitis (TBM) but neither of them did clearly explain the paraparesis. Besides, to diagnose TBM, an intact sensorium in the presence of neurological defi cits is unlikely. Systemic malignancies and GB syndrome were considered lower down on the list of differential diagnosis. Further investigation showed ESR of 80 mm/hr, strongly positive Mantoux, 5% blasts in the peripheral smear and bone marrow aspiration showed 90% blasts. MRI of the spine revealed proteinaceous fl uid (blood or blood mixed exudates) in the extradural space with spinal cord compression at upper thoracic region.The fi nal diagnosis was acute leukaemia with paraparesis due to spinal compression and extradural bleed. The strongly positive mantoux most probably was due to activation of occult TB with the immunocompromised state because of leukaemia. She was then referred to the Oncology unit for further management.