A Toddler with Acute Flaccid Paraparesis
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A Toddler with Acute Flaccid Paraparesis Sebaranjan Biswal 1 & Aranya Dubbudu 1 & G. Bala Praneeth Reddy 1 & Natabara Swain 1 & Indar Kumar Sharawat 2 & Prateek Kumar Panda 2 Received: 28 July 2020 / Accepted: 14 September 2020 # Dr. K C Chaudhuri Foundation 2020
A 3-y-old boy presented with pain in bilateral lower limbs, fever, and gait instability for the past five days. There was no history of altered mentation, seizures, preceding episodes of loose stools or upper respiratory tract infections, trauma, tick bite, dog bite or rash, sensory or bowel bladder involvement. Examination revealed stage 2 hypertension (BP ≥ 95th percentile +12 mmHg), symmetrical flaccid paraparesis, hyporeflexia, without definite sensory level. A possibility of Guillain Barré syndrome (GBS) was considered. Nerve conduction study revealed motor sensory polyneuropathy in bilateral lower limbs. However, careful clinical examination revealed bluish-black discoloration of bilateral toes (Fig. 1). The clinical possibility of a vasculitic process was considered. Investigations showed neutrophilic leukocytosis, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and normal procalcitonin levels. Coagulation profile and work up for procoagulant state including antiphospholipid antibody was negative. Skin biopsy suggested cutaneous polyarteritis nodosa (CPAN) (Fig. 2). CT angiography of abdominal and renal vessels was normal. Work up for hepatitis B, C, tuberculosis, antistreptolysin O (ASO), anti-nuclear antibodies (ANA), and antineutrophil cytoplasmic antibodies (ANCA) were negative. He was started on oral amlodipine, pulse methylprednisolone, and low molecular weight heparin and his pain and subcutaneous nodules resolved within two weeks. CPAN is a rare systemic necrotizing vasculitis affecting small and medium-sized arteries [1]. It is characterized by inflammed and thickened blood vessel walls, with narrowing of the lumen, impeded blood flow, subsequent ischemia, and
* Prateek Kumar Panda [email protected] 1
Department of Pediatrics, Kalinga Institute of Medical Sciences, Bhubaneshwar, India
2
Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand 249203, India
end-organ damage [2]. In CPAN, lesions predominantly involve skin, adjacent muscles, nerves, and joints and usually cause tender subcutaneous nodules, livedo reticularis, and ulceration involving the lower extremity. Gangrene and necrosis of fingers, petechiae, and purpura may also be found. Like systemic polyarteritis nodosa (PAN), necrotizing arteritis of small and medium-sized vessels and leukocytoclastic vasculitis with/without fibrinoid necrosis are the characteristic histopathological findings of this entity and help in establishing the diagnosis. Corticosteroids remain the first-line treatment for CPAN and other immunosuppressive agents are used in steroid unresponsive cases [3]. In a community setting, GBS remains the first and most prevalent clinical diffe
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