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Spot Dx
45-year-old female Immunosuppressed (ISS) on ART (likely HIV-positive)
Nurse
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Case Presentation
A 45-year-old female on antiretroviral therapy (ART) with a 2-month history of progressive bilateral lower limb weakness. She presents with spastic paraparesis (power 2/5) and preserved sensorium. The pelvic X-ray shows destructive changes in the lumbosacral spine. She is immunosuppressed, likely due to HIV/AIDS. The patient has been experiencing worsening symptoms over the past two months, including difficulty walking and maintaining balance. She has not had any recent trauma or infections. Her current medications include ART, and she has been adherent to her regimen. Physical examination reveals bilateral lower limb weakness, with a power of 2/5. The patient's sensory examination is normal. Laboratory results show a low CD4 count of 150 cells/μL.
Question
What is the most likely diagnosis, and which single finding most strongly distinguishes it from multiple sclerosis?
Answer
The most likely diagnosis is spinal tuberculosis (TB). The key finding that distinguishes spinal TB from multiple sclerosis (MS) is the destructive changes in the lumbosacral spine on the pelvic X-ray, which suggests vertebral involvement. In MS, vertebral involvement is not typically seen. According to the Uganda Clinical Guidelines 2023 (UCG 2023), the management of spinal TB involves starting anti-TB medication immediately. A critical complication to watch for in the next 24 hours is spinal cord compression, which requires urgent referral to a higher-level facility for further management.
Clinical Pearl
In a patient with HIV/AIDS and progressive bilateral lower limb weakness, spinal TB should be considered high in the differential diagnosis, especially when there are radiographic findings of vertebral destruction. Early initiation of anti-TB therapy is crucial to prevent further neurological deterioration.