Answer 11

How to approach such a case?

Discussions conducted by internal medicine residents:

-One opinion:

"...my impression is that there is a local destructive process in the back with this weakness as a result, and the most probable process here is Pott's disease, considering the previous history of T.B. ...."

-It seems logic from the first glance but when looking deeper things change. Follow carefully!

-One opinion:".....this is one of the muscular dystrophy disease and I would proceed directly to the muscular biopsy and EMG to confirm the diagnosis...."

-If it should be so other muscles would be also affected and during this four-year period muscular manifestations should have shown themselves.

-Another opinion:

"... I'd like to localize the problem as weakness which belongs to the neurological deficits. So in the classic neurological thinking I first localize the site of deficit in the nervous system (Where is the lesion?) rule, then postulate some possible causes (What is the lesion?) rule.

So weakness distribution in the proximal lower limbs muscles with no other muscular affection will draw my attention to a lower neurological deficits starting from the spinal cord, nerve roots and trunks, or the muscles. To choose one of them formed a difficulty to me because affection of any of the above sites would definitely involve sensory or autonomic functions and would have obvious neurological and muscular, atrophy for example, manifestations specially in a long standing suffering like this.

So I cannot deduce the disease process, but arbitrary I would choose intrinsic muscular disease...."

-Very close intuition, but there are some spinal cord pure motor diseases that can explain this muscular deficits, like amyotrophic lateral sclerosis, however negated by the absence of asymmetry, atrophy and the unsuitable age. Also there are some hereditary disorders involving this area but again negated by absence of typical distribution and manifestations in a long standing complaining patient.

 

To complete the above last intuition:

My impression was that the patient should rather have a systemic problem than a pure neurological deficit that can explain her manifestations. I gave her the clinical diagnosis of osteomalacia induced weakness and directly started to confirm by ordering Calcium levels and pelvic X-ray which all yield positive results.

Treatment was started by supplying calcium and vitamin D, with marked improvement in patient's condition without the need for biopsy!