A 70-year-old man with lower-extremity weakness and falls

Calen Frolkis; Ari Wachsman; Angela Liu; Ayoub Harb

doi:10.3949/ccjm.93a.25061

Article Figures & Data

Figures

Tables

Download figure
Open in new tab
Download powerpoint
Figure 1
Portable chest radiograph showing an 8-cm apical mass in the patient’s right lung (red arrow).
Download figure
Open in new tab
Download powerpoint
Figure 2
Xanthochromic cerebrospinal fluid in all 4 tubes.
Download figure
Open in new tab
Download powerpoint
Figure 3
(A) Sagittal section magnetic resonance image of the patient’s cervical and thoracic spine. A large right apical and upper mediastinal soft tissue mass extends posteromedially into the prevertebral soft tissues and T1 to T4 vertebrae (yellow arrow). The soft tissue mass also extends into the right epidural space at T1 to T2, and further extends into the subdural space from T2 to T4 (red arrow), causing severe leftward displacement and compression of the spinal cord. (B) Sagittal section magnetic resonance image of the thoracic, lumbar, and sacral spine. There is grade 2 anterolisthesis of the L5 vertebra over the S1 vertebra, along with an L5 pars defect (yellow asterisk). Enhancing soft tissue nodules along the surface of the distal spinal cord and cauda equina are consistent with drop metastases and leptomeningeal carcinomatosis (red arrows). An incidental Tarlov cyst at the S3 level (blue arrow) was also found.

Tables

Figures

View popup

TABLE 1

Laboratory test results

Test	Value from emergency department^a	Value from 4 months earlier^a	Reference range
Basic metabolic panel
Sodium	126 mmol/L	132	135–145
Potassium	3.8 mmol/L	4.4	3.5–5
Chloride	88 mmol/L	100	98–107
Carbon dioxide	26 mmol/L	26	21–31
Blood urea nitrogen	19 mg/dL	14	7–25
Creatinine	0.74 mg/dL	1.12	0.70–1.30
Glucose	98 mg/dL	102	70–99
Serum osmolality	262 mOsm/kg		275–295
Urine osmolality	429 mOsm/kg		50–1,400
Urine sodium	19 mmol/L		15–220
Complete blood cell count
White blood cells	15.0 × 10⁹/L	12.8	4.5–11.5
Red blood cells	4.32 × 10¹²/L	5	4.5–5.9
Hemoglobin	13.6 g/dL	15.5	13.9–16.3
Hematocrit	38.4%	45.2%	41%–53%
Mean corpuscular volume	89 fL	90.4	80–100
Mean corpuscular hemoglobin	31.4 pg/cell	31	26-34
Mean corpuscular hemoglobin concentration	35.4 g/dL	34.3	32.0–35.9
Platelet count	322 × 10⁹/L	299	150–400
Red cell distribution width–coefficient of variation	14.6%	15%	11.5%–14.5%

↵^aOut-of-range results are shown in bold.

View popup

TABLE 2

Results of the patient’s neurologic examination

Examination	Score
Examination	Right side	Left side
Muscle strength^a
Deltoid	5	5
Biceps	5	5
Triceps	5	5
Hand	4	5
Hip flexion	2	5
Knee extension	0	0
Knee flexion	0	0
Dorsiflexion	0	0
Plantarflexion	0	0

Extremity sensation
Light touch	Lower: absent up to midthigh Upper: intact	Lower: absent up to knee Upper: intact
Vibration	Lower: absent below knee Upper: intact	Lower: absent below knee Upper: intact
Joint position	Lower: absent below knee Upper: intact	Lower: absent below knee Upper: intact
Temperature	Lower and upper: intact	Lower and upper: intact
Reflexes^b
Biceps	2	2
Triceps	2	2
Brachioradialis	1	2
Patellar	0	Trace

Extremity tone	Lower: diminished Upper: normal	Lower: diminished Upper: normal

Babinski sign	Absent	Absent

↵^aGraded on a scale from 0 (no muscle activation) to 5 (full range of motion).
↵^bGraded on a scale from 0 (no reflexes) to 4 (hyperreflexia), with a score of 2 indicating normal reflexes.

View popup

TABLE 3

Physical diagnostic clues of conditions that can cause muscle weakness

Condition	Key features	Effect on reflexes	Clinical findings
Leptomeningeal disease	Multilevel neuraxial nerve roots involved, leading to asymmetric weakness	May have hyperreflexia with eventual loss of reflexes due to ongoing compression of nerve roots	With or without radicular pain
Cauda equina	Asymmetric weakness caused by 2 or more nerve roots (L2–sacrum, lumbosacral nerve roots)	May have hyperreflexia early, which ultimately leads to loss of tone and areflexia	Gradual, unilateral onset Saddle numbness (S3–S5) with or without lower-extremity sensory deficits
Conus medullaris	Symmetric weakness with prominent sphincter dysfunction and flaccid bladder and rectum paralysis (L1–L2; sacral cord segment and roots)	Less marked hyperreflexia at ankles with distal paresis and fasciculation	Sudden, bilateral onset Mixed upper motor neuron and lower motor neuron signs Perianal numbness with or without sexual deficits or impotence Leg weakness is mild
Horner syndrome	Ipsilateral eyelid ptosis	Miosis on swinging light test	Anhidrosis from ipsilateral sympathetic nerve injury
Neurogenic thoracic outlet syndrome	Intrinsic hand muscle atrophy with or without grip weakness or finger abduction	May be diminished due to muscle atrophy	With or without upper-extremity sensory deficits May have positive Spurling test^a Consider Adson maneuver^b to ensure arterial sufficiency and Pemberton sign^c to rule out superior vena cava compression
Polyneuropathy	Multifocal and asymmetric distribution	Decreased deep tendon reflexes	Paresthesia and pain that can be followed by ataxia Decreased sensation Consider testing for anti-Hu, anti-CRMP5, and antiamphiphysin antibodies

↵^aPosition the head of the seated patient by extending the neck, rotating it to the affected side, and tilting the head to the same side. The test is positive if applying downward pressure on the top of the head elicits radicular pain.
↵^bRadial pulse is lost when the patient rotates their head to the affected side and takes a deep breath.
↵^cThe patient lifts both arms overhead with forearms touching the side of the face for about 1 minute and the clinician observes for any of the following positive signs: facial congestion, cyanosis, or respiratory distress.
Based on information from reference 27.