A 50-year old male farmer, presented for the first visit to our spine clinic in December 2017 with a history of slowly progressing weakness of his bilateral lower limbs over last 4 months. Due to financial restrain, he decided not seeking medical help for his symptoms. However, in recent weeks, he was not even able to stand on his own, thereby restricting him from carrying out even most basic activities of his daily life. The patient declared no history of trauma or fall injuries. There was no fever, chronic cough, significant weight loss, or swellings elsewhere in the body, or any bladder or bowel symptoms. He had no relevant history of close contact with patients having Tuberculosis, which is among the major causes of myelopathy in our context. There was no relevant past medical or surgical illnesses, or family history of any malignancies or similar ailments.
The patient was well built, conscious and well oriented to time, place and person. There was no pallor or lymphadenopathy. His vision, as well as all cranial nerves was intact. Spinal examination revealed presence of sensory loss below T7 with exaggerated knee reflexes and up-going Babinski sign suggesting myelopathy. Vibration sense was disturbed from the D4 spinous process. Systemic examination was clinically normal. Urgent Magnetic Resonance Imaging (MRI) of the spine revealed the presence of multiple enhancing extradural lesions compressing the cord in the D3-D4 and D9-D10 thoracic region ( Figure 1). There were posteriorly based lesions with iso-hypointense in the T1 image, hypointense in the T2 image and homogenously enhancing following contrast administration.
The patient was started on Oral Prednisolone (tapering dose starting from 40mg/day) and weekly Methotrexate (7.5mg) therapy. Since then, the patient has good neurological improvement, being able to walk independently with a walking stick within 10 days. The patient could walk independently in a follow up visit at 4 weeks. Repeat CT scans of his chest revealed good resolution on the pleural based lesion as well ( Figure 4). We advised the patient to slowly reduce the drugs within the next 4 months. He was advised about regular follow up for periodic neurological and pulmonary examinations to determine early recurrence or progression of the disease.