Title : Progressive lower extremity weakness, implication vs causation
Abstract:
This case report aims to elucidate the intricate clinical presentation of a 37-year-old male with progressive lower extremity weakness and numbness. The paper seeks to explore the challenges in establishing causation amidst complex factors, including lumbar spine abnormalities, Guillain-Barre Syndrome, and the patient's recent initiation of Humira (adalimumab), a TNF-α inhibitor. The aim is to contribute insights into the diagnosis and tailored management of neurological presentations with multifaceted influences. This case illustrates the importance of considering reversible medical causes prior to considering invasive surgical interventions.
Case description: This case report details a patient presenting with a two-week history of progressive lower extremity weakness and numbness, with initial manifestations observed in the feet. Numbness radiating on the lateral aspects of his bilateral knees and lower extremities with a noticeable motor deficit in the right ankle down, with an absent ankle reflex.
Further complicating the clinical picture, the patient has a sequestered disc fragment at L5-S1, potentially contributing to the observed foot weakness. However, the recent diagnosis of Guillain-Barré Syndrome (GBS) adds complexity to establishing a clear causation. Notably, the patient recently initiated Humira (adalimumab), a tumor necrosis factor-alpha (TNF-α) inhibitor, a few months prior, and reports associating TNF-α inhibitors with demyelinating diseases, including a multiple sclerosis-like syndrome, underscore the need for careful consideration in this case.
Comprehensive investigations, including brain and spine magnetic resonance imaging (MRI), revealed multiple areas of possible nerve impingement. Focal disc herniations at L4-L5 with inferior migration, bilateral foraminal stenosis, broad disc herniation at L5-S1, with contrast enhancements of multiple cauda equina roots on the right side of the thecal sac extending from T12 to L4-L5 suggestive of possible arachnoiditis. Cerebrospinal fluid (CSF) analysis revealed elevated protein levels with a normal white blood cell count and infection was ruled out.
The decision for conservative management was made. The patient was treated with intravenous immunoglobulin (IVIG), a common therapeutic approach for GBS. In light of the complex clinical presentation and the potential association with Humira, the TNF-α inhibitor was also discontinued. Patient was later discharged after the completion of IVIG and plan was to follow up outpatient neurology and pain management for continued treatment with epidural spinal injections. Patient was lost to follow up.
Discussion: This case emphasizes the challenges in delineating causation in the context of multiple potential contributing factors, including a Disc herniations, GBS, and TNF-α inhibitor exposure for a patient presenting with lower extremity numbness and weakness. Collaborative efforts among the patient, neurologist, neurosurgery, and healthcare team are essential for a nuanced diagnosis and tailored management approach. It highlights the importance of good clinical reasoning to avoid possibly unnecessary surgical interventions and promote conservative management.
Audience Take Away:
- The case offers insights applicable to clinicians, aiding in diagnosis and tailored management of complex neurological presentations that could stem from multiple different causes. fostering a more comprehensive and effective approach to patient care.
- This case emphasizing the importance of considering reversible causes before opting for surgical interventions, promoting informed decision-making.
- The case prompts considerations about the association between TNF-α inhibitors, demyelinating diseases, lumber Disc herniations offering valuable information for designers to improve the accuracy and safety of medical interventions.
