Weakness in the limbs, impaired consciousness, this cause is surprising!

An effective treatment is abstinence from alcohol

When the main complaint is "limb weakness and incontinence", is it a simple cerebral infarction? Let's analyze it together!

Case introduction

The patient, a 57-year-old male, was admitted to the hospital
for 3 days mainly due to limb weakness with fecal and incontinence worsening in 1 month and impaired consciousness.

The patient had no obvious cause of limb weakness and incontinence before 1 month, and improved after receiving rehydration (specific dose and drug name unknown) and acupuncture treatment
.

3 days ago, the above symptoms of the patient worsened, appeared consciousness disorder, accompanied by dysphagia and choking on water, did not know family members, etc.
, no convulsions, no foaming at the mouth, no hanging eyes, etc.
, in order to seek further diagnosis and treatment, he went to the emergency department of our hospital, and checked the head CT: ischemic brain changes, brain atrophy (Figure 1).

Figure 1

There was no abnormally high signal
in the head DWI.

The history of cerebral infarction is more than 10 years old, and there are no sequelae
.
He has been drinking for more than 30 years, with an average of 2 pounds per day
.

Physical examination: no obvious abnormalities
were revealed on cardiopulmonary and abdominal examination.
Confusion, reduced coarse determination and calculation power, lack of cooperation on physical examination, bilateral pupils are equally round, diameter 3.
0mm, sensitive to light reflection
.

The gag reflex is reduced, the muscle tone of the limbs is reduced, the muscle strength of both upper limbs is grade 4, the muscle strength of both lower limbs is grade 3, and the bilateral biceps tendon reflex is symmetrically enhanced
.
The bilateral ataxia test and finger nose test were unstable, the double lower limb and knee shin tests were not cooperative, and the bilateral Babinskin sign was positive
.

■ Positioning diagnosis:

Figure 2

■ Qualitative diagnosis:

The patient is an elderly man with a history of cerebral infarction and a long-term history of alcoholism, this time with poor muscle strength in both lower limbs, difficulty swallowing, choking on water, incontinence, and no abnormal hyperintensity
in the head DWI.
Ischemic cerebrovascular disease
is not considered for the time being.

So improve the relevant examinations: blood analysis: red blood cell count: 3.
71X10¹²/L, hemoglobin: 127g/L; Biochemical items: total protein 57g/L, albumin 33.
6g/L; Five coagulation items: D-dimer quantification: 1.
18mg/L (FEU), no obvious abnormalities
in the six items of thyroid function + male tumors.

Double lower limb electroneurography + electromyography:

1.
Nerve conduction velocity measurement, the motor conduction speed of the common bifibulal nerve slowed down, the sensory conduction amplitude of the superficial nerve of the double fibula decreased, the sensory conduction amplitude of the double sural nerve was low, the right speed slowed down, and there were no abnormal changes in the remaining tested nerves;

2.
Reflex determination: the incubation period of double peroneal nerve F wave measurement is prolonged; The H-reflex of the left tibial nerve did not lead to a positive waveform, and the right latency was prolonged and the amplitude decreased.

3.
Electromyography: the light and heavy contraction of the right medial femoral muscle is not good, and no abnormal changes are seen; Abnormal changes in the muscles to be examined; Conclusion: Peripheral nerve damage of both lower limbs (motor and sensory fibers are affected, demyelinating + axonal damage);

Lower limb artery ultrasound: bilateral femoral artery, bilateral popliteal artery media-middle membrane thickening with calcification, bilateral anterior tibial artery, bilateral posterior tibial artery, bilateral dorsal foot artery wall calcification
.

Improve cranial MRI + enhancement: third ventricular and periaqueduct, thalamic symmetric T2-FLAIR hyperintensity, enhanced in sheet form; Brain atrophy (Figure 2).

Figure 3

This test
was not performed because the patient and his family refused to wear lumbar puncture.

After vitamin_B1 treatment, the clinical symptoms improved
significantly compared with before.