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Conan Doyle, the author of the world-famous detective masterpiece Sherlock Holmes, was actually a clinician at first
.
Why does a doctor have such careful thinking? In fact, in the process of exploring diseases, doctors often solve crimes like detectives, especially for complex neurological diseases
.
Therefore, Yimaitong will launch a series of columns-"The "God" Medical Detective" column, which will analyze the complex diseases of the nervous system in the form of detectives, reveal the mystery of the disease, then follow us to explore now Case! Some people compare a hospital to a battlefield without gunpowder smoke.
Fighting diseases in this battlefield will inevitably encounter a "minefield
.
"
How to cleverly "protect from lightning" is a compulsory course for every soldier
.
This article tells about an elderly woman who suffered from weakness, pain and numbness in her lower limbs, and was diagnosed with diabetes after admission.
The seemingly simple case also has a "minefield" lurking
.
What is the situation, let us find out
.
A 76-year-old woman with human evidence was admitted to the hospital for 5 days due to pain and weakness in both lower limbs
.
The patient developed bilateral lower extremity pain and weakness 5 days ago, and the pain worsened at night
.
There was no fever, no body twitches, no speech clumsy, and urination was more laborious than before
.
The diet is acceptable
.
Past history: Suffered from "Guillain-Barré Syndrome" in 2018.
He was diagnosed with "Poster Circulatory Ischemia" in the local hospital due to dizziness half a month ago, and was discharged after symptomatic treatment
.
Denies the history of hypertension, diabetes, and coronary heart disease
.
Physical examination: General vital signs are normal, mentally clear, reasonable question and answer, cranial nerve examination is normal, both upper limbs muscle strength and muscle tension are normal, both lower limbs muscle strength is 5-grade, muscle tension is normal, both lower limbs knee tendon reflexes are weakened, and pathological reflexes Not elicited, meningeal irritation signs are negative
.
The pulsations of the dorsal foot arteries on both sides were normal
.
Physical evidence blood routine: neutrophil ratio 75.
4%, platelet count 467 x10^9/L, color Doppler ultrasound of left and right lower extremities: uneven thickening of the arterial intima and media with sclerosing plaque formation
.
EMG: peripheral neuropathy
.
Fasting blood glucose 6.
98mmol/l, 2 hours postprandial blood glucose 16.
06mmol/L, glycosylated hemoglobin 6.
2%, file analysis combined with medical history, physical examination, located in the peripheral nerve, qualitative peripheral neuropathy caused by diabetes
.
After 2 days of symptomatic treatment, the patient still complained of obvious soreness and difficulty falling asleep at night
.
The family anxiously asked if there were other reasons
.
The lower limbs are not weak and can walk on their own, but the patient's numbness and soreness are obvious at night, and he can't help getting out of bed.
Is this a restless leg syndrome? Case-related knowledge points that cause secondary restless legs syndrome include: renal failure, spinal cord and peripheral neuropathy, iron and folic acid deficiency due to pregnancy and corresponding changes in sex hormones, Parkinson’s disease dopaminergic system dysfunction, and certain drugs (antidepressants, antipsychotics, histamine blockers), migraine
.
After removing the fog, the patient underwent a full spinal cord magnetic resonance to indicate degenerative changes, and no other spinal cord and lumbar lesions were seen
.
The diagnosis of diabetes is clear, and the electromyogram indicates peripheral neuropathy, which can cause restless legs
.
The reason for the weakness, soreness and numbness of the lower limbs is like a "mock doll", which is finally buckled on the "rested leg"
.
After two more days of symptomatic treatment, the patient's symptoms still did not get better, and they got a little worse
.
Although the patient's muscle strength did not change significantly, it was more difficult to walk
.
Are restless legs just the appearance, and there are "minefields" below? Inquiring about the medical history again, it was found that the patient had a previous history of "Gillan-Barre".
At that time, the symptoms turned out to be weakness in both lower limbs and numbness and soreness in the "calf"
.
I quickly did a waist puncture, and the result: the pressure was normal, the cell number was 16x10^6/L, the protein was 1.
05g/L, the glucose was 4.
9mmol/L, and the chlorine was 119.
43mmol/L
.
Final diagnosis: Guillain-Barré syndrome (variant)
.
Case-related knowledge points expansion 1.
In addition to the classical symmetry flaccid paralysis, the clinical symptom classification of Gillan-Barre also has variants
.
two.
The imitator of lower limb paraplegia Guillain-Barre ➤ Dr.
Nadim lumbosacral plexus neuropathy reported that a 49-year-old female patient with cervical cancer developed progressive lower limb paralysis and pelvic pain 10 weeks after the completion of radiotherapy.
Evidence of disease metastasis or progression
.
The bladder and bowel function were not affected
.
After extensive examination, the most likely cause may be lumbosacral plexus neuropathy caused by radiation
.
Acute paralysis of the lower limbs is a very rare complication in the treatment of gynecological cancer
.
After cervical cancer treatment, neuropathy of the lower extremities with pelvic pain and progressive bilateral flaccid paralysis is a disease that may accumulate pelvic nerves or spread to the epidural space of the spinal cord
.
After excluding tumors and other neurological diseases, radiation-induced lumbosacral plexus neuropathy was the patient's final diagnosis
.
➤When the nervous system symptoms of acute intermittent hematoporphyria occur, in addition to the psychiatric symptoms and epilepsy manifested by central nervous system involvement, there are also muscle pain manifested by peripheral nerve involvement, followed by loss of tendon reflexes and muscle weakness.
, Especially when intercostal muscles, diaphragm muscles and other muscle groups are involved, mechanical ventilation is required, and attention should be paid to distinguish it from Gillan-Barre
.
The more typical manifestation is acute motor nerve axonal damage, which can gradually progress from single limb muscle weakness to delayed paralysis of the limbs, which may be accompanied by severe muscle pain, especially in the calf
.
The domestic literature reported that a 29-year-old female patient had tortuous medical treatment
.
The patient underwent appendicitis 5 months before admission.
The patient experienced a trance, straight eyes, unresponsiveness, and weakness during the infusion the next day after the operation
.
Suspected hypokalemia, potassium supplementation did not relieve, and then agitated, serum sodium 112mmol/l, after high-concentration sodium supplementation, the patient was awake and the above symptoms relieved
.
I went to the local hospital for abdominal pain 4 months ago.
The abdominal pain lasted for 1 hour and then relieved
.
Afterwards, she was in a trance again, her eyes became straight, her limbs were weak, and her blood sodium was checked at 119mmol/l.
After high-concentration sodium supplementation, her symptoms eased again
.
One month ago, she had abdominal pain again during her menstrual period, her limbs were weak, and she was in a trance
.
Consciously have muscle pain in both lower limbs, and severe abdominal cramps, but no relief from spasm and pain relief.
At this time, hematoporphyria is considered.
After the urine is exposed to the sun, the color gradually darkens and becomes wine-colored
.
The test was positive for urinary porphobilinogen, and the blood lead and urine lead were normal
.
Diagnosed as acute intermittent hematoporphyria
.
➤Spontaneous spinal cord epidural hemorrhage Spontaneous spinal cord epidural hemorrhage, clinical manifestations of acute spinal cord compression, can be manifested as spinal cord transverse injury, can also be manifested as spinal cord hemisection syndrome
.
The cause is mostly due to spinal cord vascular malformations, but also due to anticoagulation, thrombolysis or other reasons caused by clotting mechanism obstacles
.
➤Cancerous myelopathy When there is a primary cancer in an organ other than the nervous system, there is no direct invasion and metastasis of the nervous system and neurological complications occur, which is called cancerous neuropathy, also called paraneoplastic neurological syndrome
.
Cancerous myelopathy is a cancerous non-metastatic neurological disease, which was first reported by Mamcall in 1964
.
The disease mostly occurs in lung cancer, followed by stomach cancer, prostate cancer, thyroid cancer and breast cancer
.
The pathogenesis is unclear
.
At present, there are several theories: (1) Due to the toxic effect of cancer cell metabolites, it affects metabolism, endocrine function and nutritional disorders
.
(2) The immune function of the cancer patient is low, and it is caused by the secondary virus infection
.
(3) A tumor matrix protein produced by tumor tissue can cause allergic myelitis
.
➤Thyroid storm is also called thyroid toxic crisis
.
It is a life-threatening complication of hyperthyroidism, manifested by sudden multi-system involvement, usually manifested by fever symptoms and changes in mental status, and cardiovascular involvement (tachycardia, arrhythmia, heart failure with pulmonary edema) And central nervous system involvement (anxiety, agitation, delirium, psychosis)
.
Some cases have reported thyroid crisis manifested as weakness and paralysis, manifested as Guillain-Barré syndrome (GBS)
.
A classic case review of an elderly male patient who underwent minimally invasive treatment of lumbar disc herniation, with normal muscle strength after surgery
.
On the second day after surgery, the patient developed numbness in both lower limbs and gradually decreased muscle strength to Grade 3, accompanied by dysuria and hypothermia below the groin, decreased sensation in sellar area, and normal deep sensation, located in the spinal cord, which is the anterior spinal artery Is the infarction due to another cause? Due to the presence of metal in the patient's body, MRI could not be performed, and no bone cement leakage was found on the CT scan of the lumbar spine
.
The tube bed doctor is anxious and unable to do anything.
Senior experts in our hospital recommend a lumbar puncture, except for suspected spinal hemorrhage
.
It turned out that the patient had a history of atrial fibrillation and took warfarin orally on weekdays, but the waist puncture turned out to be bloody cerebrospinal fluid
.
After several injections of cerebrospinal fluid, the patient's muscle strength returned to normal
.
The case was solved, which not only effectively treated the patients, but also avoided possible medical disputes.
It is really amazing! Ending After 5 days of treatment with C-ball, the patient can fall asleep normally at night, the symptoms of numbness and soreness in the lower limbs have improved significantly, and he can walk freely when discharged from the hospital
.
As a medical soldier, if you don't "step on thunder" when you want to fight against all kinds of diseases, you really need "lightning protection artifacts
.
"
Whether it is the insight to see the essence through the phenomenon, or the discernment from the outside to the inside, to remove the falsehood and to keep the truth, or to study and think, the pen is not to be embellished, the ingenuity is good at discovering the "minefield", and it is an expert Pointing, reappearance of aura, guidance of immortals, etc.
.
.
In short, on this battlefield, the soldiers must be strong and have a long way to go! References: 1.
Ali Alanazi, etal.
Acute Brucellosis with a Guillain-Barre Syndrome-Like Presentation: A Case Report and Literature Review.
Infect.
Dis.
Rep.
2021, 13(1), 1-10.
2.
GSC Biological and Pharmaceutical Sciences , 2019, 09(01), 098-1033.
Shen Yun, Mao Chengjie, Liu Chunfeng.
Secondary restless legs syndrome, Chinese Journal of Modern Neurological Diseases, 2013, 05.
4.
Nadeem R.
Abu-Rustum, MD et al.
AcuteLower Extremity Paralysis Following Radiation Therapy for Cervical Cancer.
Gynecologic Oncology Volume 75, Issue 1, October 1999, Pages 152-154.
5.
Yin Yingjie, Li Jianxia, Wang Lili.
1 case of spontaneous spinal epidural hemorrhage caused by warfarin, the latest medicine in the world , 2016, 71.
6.
Hou Xiaocan, Jia Yanjie, Peng Tao.
Progress in hematoporphyria and neurological manifestations, Chinese Journal of Practical Nervous Diseases, 2016, 03.
7.
Raposo Anna Julia Lacerda 1, Freire Eduardo Galvão 1, de Farias Célia Raiany Ferreira 1, Serquiz e Pinheiro Renato 2, PinheiroFrancisco Irochima 3, Guzen Fausto Pierdoná 3,
.
Why does a doctor have such careful thinking? In fact, in the process of exploring diseases, doctors often solve crimes like detectives, especially for complex neurological diseases
.
Therefore, Yimaitong will launch a series of columns-"The "God" Medical Detective" column, which will analyze the complex diseases of the nervous system in the form of detectives, reveal the mystery of the disease, then follow us to explore now Case! Some people compare a hospital to a battlefield without gunpowder smoke.
Fighting diseases in this battlefield will inevitably encounter a "minefield
.
"
How to cleverly "protect from lightning" is a compulsory course for every soldier
.
This article tells about an elderly woman who suffered from weakness, pain and numbness in her lower limbs, and was diagnosed with diabetes after admission.
The seemingly simple case also has a "minefield" lurking
.
What is the situation, let us find out
.
A 76-year-old woman with human evidence was admitted to the hospital for 5 days due to pain and weakness in both lower limbs
.
The patient developed bilateral lower extremity pain and weakness 5 days ago, and the pain worsened at night
.
There was no fever, no body twitches, no speech clumsy, and urination was more laborious than before
.
The diet is acceptable
.
Past history: Suffered from "Guillain-Barré Syndrome" in 2018.
He was diagnosed with "Poster Circulatory Ischemia" in the local hospital due to dizziness half a month ago, and was discharged after symptomatic treatment
.
Denies the history of hypertension, diabetes, and coronary heart disease
.
Physical examination: General vital signs are normal, mentally clear, reasonable question and answer, cranial nerve examination is normal, both upper limbs muscle strength and muscle tension are normal, both lower limbs muscle strength is 5-grade, muscle tension is normal, both lower limbs knee tendon reflexes are weakened, and pathological reflexes Not elicited, meningeal irritation signs are negative
.
The pulsations of the dorsal foot arteries on both sides were normal
.
Physical evidence blood routine: neutrophil ratio 75.
4%, platelet count 467 x10^9/L, color Doppler ultrasound of left and right lower extremities: uneven thickening of the arterial intima and media with sclerosing plaque formation
.
EMG: peripheral neuropathy
.
Fasting blood glucose 6.
98mmol/l, 2 hours postprandial blood glucose 16.
06mmol/L, glycosylated hemoglobin 6.
2%, file analysis combined with medical history, physical examination, located in the peripheral nerve, qualitative peripheral neuropathy caused by diabetes
.
After 2 days of symptomatic treatment, the patient still complained of obvious soreness and difficulty falling asleep at night
.
The family anxiously asked if there were other reasons
.
The lower limbs are not weak and can walk on their own, but the patient's numbness and soreness are obvious at night, and he can't help getting out of bed.
Is this a restless leg syndrome? Case-related knowledge points that cause secondary restless legs syndrome include: renal failure, spinal cord and peripheral neuropathy, iron and folic acid deficiency due to pregnancy and corresponding changes in sex hormones, Parkinson’s disease dopaminergic system dysfunction, and certain drugs (antidepressants, antipsychotics, histamine blockers), migraine
.
After removing the fog, the patient underwent a full spinal cord magnetic resonance to indicate degenerative changes, and no other spinal cord and lumbar lesions were seen
.
The diagnosis of diabetes is clear, and the electromyogram indicates peripheral neuropathy, which can cause restless legs
.
The reason for the weakness, soreness and numbness of the lower limbs is like a "mock doll", which is finally buckled on the "rested leg"
.
After two more days of symptomatic treatment, the patient's symptoms still did not get better, and they got a little worse
.
Although the patient's muscle strength did not change significantly, it was more difficult to walk
.
Are restless legs just the appearance, and there are "minefields" below? Inquiring about the medical history again, it was found that the patient had a previous history of "Gillan-Barre".
At that time, the symptoms turned out to be weakness in both lower limbs and numbness and soreness in the "calf"
.
I quickly did a waist puncture, and the result: the pressure was normal, the cell number was 16x10^6/L, the protein was 1.
05g/L, the glucose was 4.
9mmol/L, and the chlorine was 119.
43mmol/L
.
Final diagnosis: Guillain-Barré syndrome (variant)
.
Case-related knowledge points expansion 1.
In addition to the classical symmetry flaccid paralysis, the clinical symptom classification of Gillan-Barre also has variants
.
two.
The imitator of lower limb paraplegia Guillain-Barre ➤ Dr.
Nadim lumbosacral plexus neuropathy reported that a 49-year-old female patient with cervical cancer developed progressive lower limb paralysis and pelvic pain 10 weeks after the completion of radiotherapy.
Evidence of disease metastasis or progression
.
The bladder and bowel function were not affected
.
After extensive examination, the most likely cause may be lumbosacral plexus neuropathy caused by radiation
.
Acute paralysis of the lower limbs is a very rare complication in the treatment of gynecological cancer
.
After cervical cancer treatment, neuropathy of the lower extremities with pelvic pain and progressive bilateral flaccid paralysis is a disease that may accumulate pelvic nerves or spread to the epidural space of the spinal cord
.
After excluding tumors and other neurological diseases, radiation-induced lumbosacral plexus neuropathy was the patient's final diagnosis
.
➤When the nervous system symptoms of acute intermittent hematoporphyria occur, in addition to the psychiatric symptoms and epilepsy manifested by central nervous system involvement, there are also muscle pain manifested by peripheral nerve involvement, followed by loss of tendon reflexes and muscle weakness.
, Especially when intercostal muscles, diaphragm muscles and other muscle groups are involved, mechanical ventilation is required, and attention should be paid to distinguish it from Gillan-Barre
.
The more typical manifestation is acute motor nerve axonal damage, which can gradually progress from single limb muscle weakness to delayed paralysis of the limbs, which may be accompanied by severe muscle pain, especially in the calf
.
The domestic literature reported that a 29-year-old female patient had tortuous medical treatment
.
The patient underwent appendicitis 5 months before admission.
The patient experienced a trance, straight eyes, unresponsiveness, and weakness during the infusion the next day after the operation
.
Suspected hypokalemia, potassium supplementation did not relieve, and then agitated, serum sodium 112mmol/l, after high-concentration sodium supplementation, the patient was awake and the above symptoms relieved
.
I went to the local hospital for abdominal pain 4 months ago.
The abdominal pain lasted for 1 hour and then relieved
.
Afterwards, she was in a trance again, her eyes became straight, her limbs were weak, and her blood sodium was checked at 119mmol/l.
After high-concentration sodium supplementation, her symptoms eased again
.
One month ago, she had abdominal pain again during her menstrual period, her limbs were weak, and she was in a trance
.
Consciously have muscle pain in both lower limbs, and severe abdominal cramps, but no relief from spasm and pain relief.
At this time, hematoporphyria is considered.
After the urine is exposed to the sun, the color gradually darkens and becomes wine-colored
.
The test was positive for urinary porphobilinogen, and the blood lead and urine lead were normal
.
Diagnosed as acute intermittent hematoporphyria
.
➤Spontaneous spinal cord epidural hemorrhage Spontaneous spinal cord epidural hemorrhage, clinical manifestations of acute spinal cord compression, can be manifested as spinal cord transverse injury, can also be manifested as spinal cord hemisection syndrome
.
The cause is mostly due to spinal cord vascular malformations, but also due to anticoagulation, thrombolysis or other reasons caused by clotting mechanism obstacles
.
➤Cancerous myelopathy When there is a primary cancer in an organ other than the nervous system, there is no direct invasion and metastasis of the nervous system and neurological complications occur, which is called cancerous neuropathy, also called paraneoplastic neurological syndrome
.
Cancerous myelopathy is a cancerous non-metastatic neurological disease, which was first reported by Mamcall in 1964
.
The disease mostly occurs in lung cancer, followed by stomach cancer, prostate cancer, thyroid cancer and breast cancer
.
The pathogenesis is unclear
.
At present, there are several theories: (1) Due to the toxic effect of cancer cell metabolites, it affects metabolism, endocrine function and nutritional disorders
.
(2) The immune function of the cancer patient is low, and it is caused by the secondary virus infection
.
(3) A tumor matrix protein produced by tumor tissue can cause allergic myelitis
.
➤Thyroid storm is also called thyroid toxic crisis
.
It is a life-threatening complication of hyperthyroidism, manifested by sudden multi-system involvement, usually manifested by fever symptoms and changes in mental status, and cardiovascular involvement (tachycardia, arrhythmia, heart failure with pulmonary edema) And central nervous system involvement (anxiety, agitation, delirium, psychosis)
.
Some cases have reported thyroid crisis manifested as weakness and paralysis, manifested as Guillain-Barré syndrome (GBS)
.
A classic case review of an elderly male patient who underwent minimally invasive treatment of lumbar disc herniation, with normal muscle strength after surgery
.
On the second day after surgery, the patient developed numbness in both lower limbs and gradually decreased muscle strength to Grade 3, accompanied by dysuria and hypothermia below the groin, decreased sensation in sellar area, and normal deep sensation, located in the spinal cord, which is the anterior spinal artery Is the infarction due to another cause? Due to the presence of metal in the patient's body, MRI could not be performed, and no bone cement leakage was found on the CT scan of the lumbar spine
.
The tube bed doctor is anxious and unable to do anything.
Senior experts in our hospital recommend a lumbar puncture, except for suspected spinal hemorrhage
.
It turned out that the patient had a history of atrial fibrillation and took warfarin orally on weekdays, but the waist puncture turned out to be bloody cerebrospinal fluid
.
After several injections of cerebrospinal fluid, the patient's muscle strength returned to normal
.
The case was solved, which not only effectively treated the patients, but also avoided possible medical disputes.
It is really amazing! Ending After 5 days of treatment with C-ball, the patient can fall asleep normally at night, the symptoms of numbness and soreness in the lower limbs have improved significantly, and he can walk freely when discharged from the hospital
.
As a medical soldier, if you don't "step on thunder" when you want to fight against all kinds of diseases, you really need "lightning protection artifacts
.
"
Whether it is the insight to see the essence through the phenomenon, or the discernment from the outside to the inside, to remove the falsehood and to keep the truth, or to study and think, the pen is not to be embellished, the ingenuity is good at discovering the "minefield", and it is an expert Pointing, reappearance of aura, guidance of immortals, etc.
.
.
In short, on this battlefield, the soldiers must be strong and have a long way to go! References: 1.
Ali Alanazi, etal.
Acute Brucellosis with a Guillain-Barre Syndrome-Like Presentation: A Case Report and Literature Review.
Infect.
Dis.
Rep.
2021, 13(1), 1-10.
2.
GSC Biological and Pharmaceutical Sciences , 2019, 09(01), 098-1033.
Shen Yun, Mao Chengjie, Liu Chunfeng.
Secondary restless legs syndrome, Chinese Journal of Modern Neurological Diseases, 2013, 05.
4.
Nadeem R.
Abu-Rustum, MD et al.
AcuteLower Extremity Paralysis Following Radiation Therapy for Cervical Cancer.
Gynecologic Oncology Volume 75, Issue 1, October 1999, Pages 152-154.
5.
Yin Yingjie, Li Jianxia, Wang Lili.
1 case of spontaneous spinal epidural hemorrhage caused by warfarin, the latest medicine in the world , 2016, 71.
6.
Hou Xiaocan, Jia Yanjie, Peng Tao.
Progress in hematoporphyria and neurological manifestations, Chinese Journal of Practical Nervous Diseases, 2016, 03.
7.
Raposo Anna Julia Lacerda 1, Freire Eduardo Galvão 1, de Farias Célia Raiany Ferreira 1, Serquiz e Pinheiro Renato 2, PinheiroFrancisco Irochima 3, Guzen Fausto Pierdoná 3,
