 FEVER for 3 weeks.  HEADACHE for 1 week.  RETENTION OF URINE for 3 days.  DIFFICULTY IN WALKING for 3 days.

 FEVER for 3 weeks - of high grade, continuous, not associated with chills or rigors No H/O exanthematous rashes  HEADACHE for 1 week, occipital, associated with photophobia, not associated with nausea or vomitting.  RETENTION OF URINE for 3 days, was brought catheterised at a pvt hosp.  H/O Loss of appetite +, H/O wt loss +  No H/O cough with expectoration.

 H/O difficulty in walking,  H/O difficulty in squatting,  H/O slipping of chappals while walking.  H/O lancinating pain at back radiating to both lumbar region  H/O diminished sensations in lower limbs  No H/S/O upperlimb weakness/loss of sensations.  H/O altered sensorium +.  No H/O convulsions/ involuntary movts/abnormalities of speech.  H/O urinary retention for 3 days.  No H/S/O cranial nerve palsies  No H/S/O cerebellar disturbances

 No H/O vaccination/ dog bite.  No H/O trauma. PAST HISTORY:  No H/O of similar illness in past.  No H/O PTB-ATT/ Exposure.  No H/O HTN/DM/BA. PERSONAL HISTORY:  Mixed diet,  No bowel /bladder disturbances until admission  No h/o addictions. FAMILY HISTORY:  No significant medical history.

 Pt moderately built, nourished.  Conscious, irritable, disoriented,Febrile  No pallor/cyanosis/ icterus.  No lymphadenopathy/ clubbing/ pedal edema.  No neurocutaneous markers.  VITALS:  P.R: 106/mt, regular, felt in all peripheries,  B.P: 120/80 mmHg, supine position.  R.R: 20/mt, regular  Temp : febrile.  J.V.P: not raised.

Higher functions: conscious irritable and disoriented. Rt handed No abnormalities of speech No cranial nerve deficits. FUNDUS:B/L early Papilloedema

MOTORSYSTEM DAY 1 DAY 3 RightLeftRightLeft BULK U.L & L.L normal TONEU.L normal hypo L.L Hypo POWER U.L PROX 4/5 3/5 DIST 4/5 3/5 L.L PROX 3/5 0/5 DIST 3/5 0/5

REFLEXES DAY 1DAY 3 ABDOMINALPRESENT PLANTARSUPGOING BICEPSPRESENT TRICEPSPRESENT SUPINATORPRESENT KNEEJERKABSENT ANKLE JERKABSENT

 SENSORY SYSTEM: Loss of pain, temp, touch, pressure, vibration sensation below L1 level. No sensory deficits involving upper limbs  CEREBELLAR FUNCTIONS & GAIT: could not be tested.  NECK RIGIDITY +  KERNIGS & BRUDZINSKIS SIGN present.  No abnormalities of spine and cranium.  OTHER SYSTEMS: CLINICALLY NORMAL.

 ACUTE MENINGOENCEPHALITIS OF ?TUBERCULOUS ETIOLOGY WITH FLACCID QUADRIPARESIS L.L > U.L. MYELORADICULITIS LOSS OF ALL SENSORY MODALITIES BELOW L1 AND INVOLVEMENT OF BLADDER.

 TUBERCULOUS MENINGOENCEPHALOMYELORADICULITIS WITH ACUTE QUADRIPARESIS, WITH SENSORY LOSS BELOW L1 AND BLADDER DYSTONIA.

 Bld sugar:77mg/dl  S.urea:26mg/dl  S.creatinine: 0.8mg/dl  CBC-TC-7,600: DC-P47%, L50%,E3% Hb% gm/dl ESR – 20 mm/hr U/E- alb – nil, sugar- nil, dep – 0 to 2 pus cells, 0 to 2 RBC. ECG – NORMAL CHEST – XRAY - NORMAL

 CSF–ANALYSIS: glucose – 20 mg% proteins – 95 mg% globulins - + cells – 98/cumm-90% lym AFB – NEG for org GRAMS – NEG for org. INDIA INK – NEG for cryptococci.  VDRL – Negative  HIV elisa – Negative

 1. SLIGHTLY PROMINENT LEPTOMENINGEAL CONTRAST ENHANCEMENT WITH SULCAL EFFACEMENT – FEATURES S/O LOW GRADE MENINGITIS.  2.NO EVIDENCE OF ABCESS, GRANULOMAS, SUBDURAL EFFUSION OR OTHER INTRACRANIAL SPACE OCCUPYING LESION ARE SEEN.

 MRI – BRAIN: evidence of leptomeningeal &tentorial blush noticed  Discrete exudates noticed in basal cisterns, tentorial leaf & subarachnoid spaces.  Thickening of both optic nerve sheath complex.  Diffuse thickening of entire spinal leptomeninges.  Exudates in cervical cord and conus medullaris.  Thickening, enlargement & enhancement of cauda equina nerve roots.  FINDINGS S/O : TUBERCULAR MENINGES, SPINAL ARACHNOIDITIS MYELORADICULITIS AND SEQUELAE.

 Pt was admitted with paraparesis and later developed paraplegia,with wasting & U.L weakness.  PT treated with STEROIDS, daily ATT & PHYSIOTHERAPY.  After 3 weeks of treatment Patient is improving with gradual regain in power in lower limbs to a Grade 2/5 and upper limbs, 4/5, with positive reflexes in both U.L & L.L, and sensory improvement, but not yet achieved bladder control.