Mr. GCSR, a 47-year-old male shopkeeper, presented with weakness in his lower and upper limbs, tingling and numbness in his hands and feet, and bladder disturbances over the past few months. He had a history of tuberculosis meningitis 20 years ago. MRI showed a syrinx from C3 to D11 with tuberculous arachnoiditis, likely causing polyradiculoneuropathy. Treatment with antitubercular drugs and steroids led to improvement of symptoms. The case highlights the importance of considering recurrent tuberculosis in patients with syringomyelia and arachnoiditis, as timely treatment can resolve symptoms.

1. RETURN OF THE
TROUBLE-TUBERCULOUS
ARACHNOIDITIS
WITH SYRINGOMYELIA-A CASE REPORT
BY-Akash
Srivatsav T
Moderated by-
Dr.N.V.Sundarachary MD;DM
Dr.U.Veramma MD;DM
Dr.R.Lalitha MD.

2. Patient Particulars
Name Mr.GCSR
Age 47 years
Sex Male
Marital status Married with a child
Occupation Shopkeeper
Address Guntur
Regd no A030616
DOA 14-07-2014
DOD 21-07-2014

3. Chief symptoms of-
• Weakness of both lowerlimbs since six months
• .
Weakness of both upperlimbs for three
months.
• Tingling, numbness and paraesthesias of two
months duration.
• Bladder diturbances of two months duration

4. History Of Present Illness
• Weakness of both the lower limbs in the form
of inability to getup from sitting and
Squatting positions, climbing up-stairs, auto-rikshaw
and bus which was associated with stiffness.

5. Weakness of both hands while
performing fine finger movements like
mixing food and writing for three
months.

6. Tingling, numbness and paraesthesias of both
hands and feet for three months which was first
observed in the feet with no subjective loss of
sensations.
Girdle sensation around the upper trunk below
the nipples.

7. Micturition disturbances like
urgency,
frequency,
overflow incontinence.
Sexual dysfunction in the form of erection and
ejaculation difficulties

8. No history of
• Speech and language disturbances,
• Disturbances of higher mental functions in any
form,
• Cranial nerve involvement in any form,
• Weakness of proximal upperlimb and distal
lowerlimb musculature.

9. No history suggestive of-
• Involvement of cerebellum and meninges,
• Raised IntraCranial Tension,
• Gait disturbances.

10. Past history
• Diagnosed to have TB meningitis 20 years
ago and received ATT for 2 years.
• Underwent lumbar laminectomy 20 years
back.

11. General condition on examination-
Conscious, coherent and oriented.
Moderately built and nourished
No- Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Pedal oedma

12. Vitals-
Afebrile
BP-130/80 mm of Hg
PR-78/min
RR-16/min

13. CNS examination-
Right hand dominant
Speech and language – Normal
Higher mental functions- Normal
Cranial nerves- Normal

14. Motor examination
Bulk –Normal in all the four limbs
Tone- Spasticity of all the four limbs

15. Power -
Upper Limbs
Muscle group Right Left
Shoulder 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Abduction 5/5 5/5
Adduction 5/5 5/5
Elbow 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Wrist 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Hand grip 90 % 90 %

16. Lower limbs
Muscle group Right Left
Hip 4/5 4 /5
Flexion 4/5 4/5
Extension 4/5 4/5
Abduction 4/5 4/5
Adduction 4/5 4/5
Knee 5/5 5/5
Flexion 5/5 5/5
Extension 5/5 5/5
Ankle 5/5 5/5
Dorsi flexion 5/5 5/5
Plantar flexion 5/5 5/5
EHL Normal Normal
EDL Normal Normal

17. Reflexes
Superficial reflexes – Present
Plantar : Bilateral Equivocal
Deep Tendon
Reflexes
Biceps Triceps Supinator Knee Ankle
Right 3 + 3+ 3+ 3 + Absent
Left 3+ 3+ 3+ 3+ Absent

18. Sensory Examination
Cutaneous – Pain and Temperature intact
Joint position sense and vibration – Absent in all the four limbs
*In upper limbs till the wrist joints
*In lower limbs upto the knees
Loss of vibration upto – T4 vertebral level
No meningeal signs
No signs of raised ICT

19. Provisional Diagnosis
Spastic quadriparesis with peripheral
neuropathy

20. Differential diagnosis
• Spinal tuberculosis
• Other causes of myelopathy.

21. INVESTIGATIONS :
Investigation Result
Hb % 10.2gm/dL
RBS 78mg%
ESR 40mm in 1st hr
Blood Urea 14mg%
Serum Creatinine 0.8mg%
Sodium 157mEq/L
Potassium 4.1mEq/L
Chloride 126mEq/L
HIV I Non reactive
HIV II Non reactive
HbsAg Negative
HCV Negative

22. CSF Analysis
Total Count : 696 cells/cumm
Differential Count : Neutrophils - 80
Lymphocytes- 20
Protein : 855 mg/dL
Glucose : 100mg/dL
PANDYS : Positive
ADA – CSF Fluid : 0.9 U/L
PCR for TB antigen : Positive

23. IMAGING
STUDIES

26. MRI of whole spine
• Syrinx extending from C3 to D11 with maximum diameter measuring 5.8mm in the
dorsal region.
• Status post laminectomy at L4 - L5 level.
• Bilateral facetal hypertrophy at L4 – L5 level.
• Posterior central protrusion at L4 – L5 level causing impingement over the thecal
sac with narrowing of bilateral neural foramina causing compression over the
exciting nerve roots.
• Crowding of thecal sac at L4 level with increased epidural fat at this level.
• Loculation of CSF opposite from D4 to D6 level on the posterior aspect.
 Features represent syrinx with associated sequelae of arachnoiditis.

27. Nerve conduction studies-
 Decreased CMAP amplitudes.
 Absent F-waves
 Absent SNAPs
 Axonal motor sensory polyradiculoneuropathy .

28. Final diagnosis
Type-III-C Syringomyelia
Extending from C3-D11 with
tuberculous arachnoiditis leading to
Polyradiculoneuropathy.

29. Treatment
• Tab Rifampicin 600mg OD
• Tab Isoniazide 450mg OD
• Tab Pyrazinamide 750mg BD
• Tab Ethambutol 1000mg OD
• Tab Prednisolone 1mg/kg body wt in tappering
doses
• Tab Tolperisone hydrochloride 150mg OD
• Tab Pyridoxine 40mg OD
• Tab Calcium OD
• Syp Potassium

30. Outcome
• The patient reported improvement of
I. Tingling, numbness and parasthesias of hands
and feet.
II. Weakness of the upper and lower limb
musculatures.
III. Micturition disturbances.

31. Discussion
Tuberculosis remains one of the
treatable but troublesome
disorders affecting central
nervous system.

34. A high index of suspicion and detailed
evaluation revealed the presence of a
coexisting, medically treatable condition in
the patient who also had syringomyelia
which however did not explain his
symptomatology.
Also surgery is deferred in our patient.

35. Conclusion
Tuberculous arachnoiditis resulting in syringomyelia is a
rare and late complication. Our patient has recurrence of
tuberculosis which produced the clinical picture .Indepth
knowledge of the pathophysiology and meticulous workup are
the cornerstones in successful management of such cases .

36. Bibliography
• Adams and Victor's Principles of
Neurology, Ninth Edition
• Bradley's Neurology in Clinical Practice, 6th ed.