Reason of Fever with Numbness of Both Limbs

Fever with numbness of both lower limbs, do you know the reason?

A female patient 65 years old, was admitted to the hospital due to numbness and numbness of both lower limbs in one month.

The patient began to have numbness of both lower extremities with no obvious inducement and prodromal symptoms more than 1 month ago, from the distal end to the lower leg, and then weakness, difficulty walking, no headache, dizziness, no rotation of the sight, no dysfunction, no weakness and numbness of the upper limbs.

In order to seek further diagnosis and treatment, it is planned to "sensory abnormalities of both lower extremities" admitted to the interventional department of our hospital.

 

Physical examination: cooperation of clearing, clear speech, soft neck without resistance, negative Klinefelter sign, isometric circle of double pupils, 3 mm in diameter, light reflection, symmetrical bilateral patterns, center tongue extension, uniform heart rhythm, all valves.

No murmurs were heard in the auscultation area, breathing sounds of both lungs were clear, no obvious dry and wet rales were heard, and the abdomen was soft without tenderness and rebound pain.

Reflexes of upper limbs and bilateral knees were symmetrical (++), bilateral reflexes of ankles were reduced, acupuncture sensation below the socks of both lower limbs decreased, and bilateral pathological signs were not elicited.

 

2019-05-30 Blood routine + CRP: white blood cell count 10.72x10 ^ 9 / L ↑, neutrophil classification 75.7% ↑, hemoglobin 98 g / L ↓, hypersensitive C-reactive protein 77.1 mg / L ↑; calcitonin Original: 0.40 ng / ml.

 

Chest CT: multiple proliferations of both lungs and a few fibrous foci. Both sides of the pleura are scattered and thickened.

Lumbar spinal cord MR: There is no obvious abnormality in lumbar spinal water imaging. Lumbar scoliosis deformity, lumbar degenerative changes.

 

After admission, the patient developed fever (temperature chart below), no cough and sputum, no abdominal pain, diarrhea, no chest tightness, shortness of breath, no urinary urinary dysuria, and empirical infusion of cefuroxime sodium 1.5 g intravenously for 12 hours to prevent infection.

 

Considering that the patient's infection site is unclear and the cause of fever is unknown, he was transferred to an infectious disease department for further diagnosis and treatment.

 

After admission, the lumbar puncture was perfect, and no abnormalities were found in the cerebrospinal fluid examination; the bone marrow puncture was sent for routine + culture, and the results returned no abnormalities.

 

EMG: 1. The somatosensory evoked potentials of the posterior tibial nerves of both lower limbs are obviously abnormal (mixed peripheral and central). 2. Abnormality of somatosensory evoked potentials in the median nerve of both upper limbs (peripheral).

 

ANCA: ANCA (perinuclear type) positive (++ 1: 32) ↑, myeloperoxidase 126.6RU / ml ↑.

 

Head enhancement MR: Dotted DWI high signal in parietal cortex area, except for small infarcts, please combine clinical.

 

The patient had no localization of infection, and his fever accompanied by numbness in both lower limbs considered ANCA-associated vasculitis, which involved peripheral nerves.

The consultation of rheumatology and immunology department believes that hormone anti-inflammatory treatment is needed, and it is recommended to refer to the department for further diagnosis and treatment.

 

While waiting for the bed, the patient developed chest tightness and shortness of breath, and rechecked the chest CT:

Multiple exudative lesions of both lungs, considering the possibility of coexistence of inflammation and pulmonary edema. Multiple nodules in both lungs.

A small amount of effusion on both sides of the chest cavity. A little fluid in the pericardium. The bilateral pleura was scattered with nodular thickening and partial calcification.

 

Blood routine + CRP: white blood cell count 12.34x10 ^ 9 / L ↑, neutrophil classification 86.8% ↑, hemoglobin 93 g / L ↓, hypersensitive C-reactive protein 84.1 mg / L ↑; calcitonin Original: 0.71 ng / ml.

 

Brain natriuretic peptide precursor: 12100 pg / ml.

 

The patient's lung inflammation rapidly progressed within a short period of time. Considering cardiac insufficiency and pulmonary infection, meropenem 0.5 g q 6 h was used for anti-infection, cardiotonic, diuretic, and vasodilator therapy.

The patient's ANCA-associated vasculitis combined with peripheral nerve involvement, plus methylprednisolone 40 mg bid to control the primary disease, may be treated with gamma globulin shock treatment, but the patient was complicated with left heart failure, so he was suspended.

 

After treatment with hormones such as anti-inflammatory, anti-heart failure, and anti-infection, the patient's symptoms improved and he was discharged.

 Cyclophosphamide treatment

The patient was admitted to the hospital again. At that time, oral prednisone 60 mg / day was taken, the body temperature was normal, there was no chest tightness, shortness of breath, no joint swelling and pain, and no limb numbness was further aggravated. Cyclophosphamide treatment given. The condition is stable, and the clinic is followed up.

 

Vasculitis

Vasculitis is the presence of inflammatory cells in the blood vessel wall and is accompanied by reactive damage to the wall structure. The size, type and location of affected blood vessels in different types of vasculitis are also different. Vasculitis can be primary or secondary to other diseases. The exact pathogenesis of these diseases is unknown.

 

Vasculitis has a wide range of clinical manifestations, making the management of such diseases particularly difficult. The initial onset of vasculitis is often rapid. Delayed diagnosis or failure to identify the extent of disease involvement and control of disease progression can lead to serious conditions that can sometimes be fatal and require rapid identification and treatment. The symptoms of the affected organ may reflect a single or multiple organ disease. The distribution of affected organs may suggest a specific type of vasculitis.

 

Non-infectious vasculitis

The classification of non-infectious vasculitis is mainly based on the main size of the affected blood vessels. Large vessel vasculitis mainly affects large arteries, including multiple aortitis and giant cell arteritis. Medium-sized vasculitis mainly affects medium-sized arteries, such as Kawasaki disease and polyarteritis nodosa.

Small vessel vasculitis mainly involves small arteries and capillaries, such as ANCA-associated vasculitis, cryoglobulinemia vasculitis, IgA vasculitis, and anti-glomerular basement membrane disease. There is also a type of vasculitis that can affect blood vessels of different sizes.

 

ANCA-associated vasculitis is a type of necrotizing vasculitis, with no obvious immune complex deposition, mainly involving small blood vessels, with myeloperoxidase specific ANCA (MPO-ANCA) or protease 3 specific ANCA (PR3-ANCA) . ANCA-negative vasculitis may also occur, referring to other aspects that meet the definition of ANCA-associated vasculitis, but the ANCA serological test result is negative.

 

Doses of Glucocorticoids

The treatment principles of vasculitis are similar to many other systemic autoimmune rheumatic diseases, but the treatment plan depends on the nature and severity of the specific disease. In general, the goal of initial treatment is to induce disease remission. Treatment options include the use of medium to high doses of glucocorticoids, and some types of vasculitis require the addition of immunosuppressive agents.

 Once the condition is alleviated, the dose of glucocorticoid is usually reduced steadily according to the patient's tolerance to control the drug-induced toxicity. The goal of the maintenance remission phase is to maintain control of disease activity, prevent disease recurrence after drug reduction or withdrawal, and minimize the risk of drug toxicity.

 

Author's Bio

Name: Ian Skyler

Education: MBBS, MD

Occupation: Medical Doctor 

Specialization: Community Medicine, General Surgery, Natural Treatment

Experience: 18 Years as a Medical Practitioner