Dr. Abhishek Srivastava: TB Meningitis squeale with spastic paraparesis

    Tuberculosis is one of the most common and devastating diseases affecting mankind. India has largest population suffering from tuberculosis and its sequel. It can affect lungs, brain, spinal cord, bones, intestines, etc and has devastating consequences from coma to paralysis.

    Mr X, 54 years old male was admitted under Dr. Abhishek Srivastava’s care on 31/07/2015. He was a known case of TB Meningitis squeale with spastic paraparesis who was non ambulatory since last 4 years. He suffered a fall with suspected seizures on the day of admission before reaching the hospital. On examination he was conscious, alert, answering questions and had a contused lacerated wound over his right eye. He had good power in all four limbs but his lower limbs had developed severe spasticity and resultant contractures .He was dependent for his all Activities of daily living , bed bound with contractures in hip and knee which further added in severe deconditioning and decreased endurance. Inspite of having some power in bilateral lower limbs he was never rehabilitated to improve or maximize functional independence in the last four years.

    Physician supervised inpatient comprehensive neurorehabilitation treatment program was started comprising of spasticity management with oral medications, management of osteoporosis with bisphosphonates, Inj. Botulinum toxin injected in bilateral hamstring muscles, physical therapy to improve strength, balance, standing, endurance and gait training and occupational therapy to improve functional and activities and daily living training, and orthotics to support knee and ankle. As he was bedbound for 4 years, it was very difficult to initiate walking. So Robotic assisted treadmill gait training (Lokomat TM) was initiated to improve gait and motor recovery. This is one of the latest and high end technologies to initiate walking in any person with muscle paralysis. Anyone with weakness of both lower limbs due to spinal cord injury or disease, one side weakness due to stroke or traumatic brain injury, and all four limb paralysis due to brain or spinal cord injury can be made to walk on this training system to initiate neuroplasticity and enhanced motor and functional recovery.

    He had bilateral knee pain due to joint degenerative changes interfering with therapy and hence underwent bilateral knee intra-articular steroid injection. Stiffness and spasticity in knee continued to hamper mobility training and hence he underwent Inj. Botox procedure (400 Units) in bilateral hamstrings and bilateral ankle plantar flexors along with bilateral below knee corrective cast applied with ankles in maximal possible correction. Cast was removed after one week and mobility training was reattempted but he continued to have pain and stiffness in bilateral knee and ankle during robotic training. Dr. Navita Purohit’s (pain medicine) opinion was sought and he underwent bilateral tibial nerve block under USG guidance on 07-10-2015, which further improved ankle movement and he was able to bear weight on the ankle with improved stiffness in knee. He started walking with walker but still had left ankle pain (medial side) which hampered full weight bearing and altered walking pattern.USG was done which was suggestive of subcutaneous edema with no muscle tear and on Dr. N Purohit’s advice underwent left posterior tibial nerve block.Pain reduced and walking pattern improved further.

    He continued inpatient physician supervised multidisciplinary neurorehab program for 3 months and at discharge was able to walk with ankle supports and walker and was totally independent for self care activities and indoor ambulation.