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Abstract: Viral myelitis is an inflammatory change in the spinal cord caused by viral infection, which results in neurological dysfunction. The disease is severe and progresses rapidly, requiring early detection and treatment. In this case, the patient was diagnosed with viral myelitis because of weakness in both lower extremities, accompanied by weakness in the right upper extremity. After active and standardized drug treatment, the patient’s condition was stabilized and muscle strength was restored.
Basic information】Male, 56 years old
Disease Type】Viral myelitis
Hospital】Shandong Provincial Third Hospital
Date of consultation】May, 2020
Treatment plan】Medication (Ginkgo biloba extract tablets + methylprednisolone tablets + ganglioside oligopeptide + cefoperazone sodium sulbactam sodium for injection + human blood gammaglobulin)
[Treatment period] Hospitalization for 18 days, outpatient follow-up after 1 month
Treatment effect】The patient’s condition is stable and muscle strength has been restored.
I. Initial consultation
The patient, Mr. Guo, developed weakness in both lower extremities and right upper extremity after diarrhea 1 week ago, and began to consider the possibility of cerebral infarction. Combined with the history of diarrhea, neurological examination was performed, suggesting mental clarity, answering tangential questions, decreased muscle strength of both lower and upper limbs, disappearance of tendon reflexes of both lower limbs, and no pathological signs were elicited, and the preliminary diagnosis of viral myelitis was made at the outpatient clinic. The disease is serious and has the possibility of progression. It is recommended to hospitalize and further improve the lumbar puncture examination as well as the blood sampling and laboratory examination, and the family expressed understanding and active cooperation.
II. Treatment process
The patient was admitted to the hospital and underwent complete blood tests for routine blood, liver and kidney function, ion, blood glucose, and cardiac enzymes, suggesting elevated lymphocytes and a high probability of viral infection. The cervical MRI showed that the cervical spine had unclear and slightly long borders and abnormal T1 and T2 signals, which were significantly worse than before, and myelitis was considered. Ginkgo biloba extract tablets, methylprednisolone tablets, human blood gammaglobulin, cefoperazone sodium sulbactam sodium for injection and ganglioside oligopeptide were given to reduce spinal edema, anti-infection and nourish peripheral nerves. The patient was discharged from the hospital after 18 days of stable condition. The patient was instructed to follow up as an outpatient in 1 month.
III. Treatment effect
After 1 week, the numbness and weakness of the limbs were at the plateau stage and did not aggravate further. Later, acupuncture and physiotherapy and functional rehabilitation of the limbs were given, and the muscle strength of the limbs was better than before when the patient was discharged from the hospital. It is recommended that active rehabilitation training within six months, together with acupuncture and electrotherapy, will help the recovery of neurological dysfunction.
IV. Notes
We are glad that the patient’s condition is stable after treatment. During the treatment period, the patient should pay attention to regular turning, good skin care to avoid pressure sores, massage the limb muscles to avoid lower limb vein thrombosis. Pay attention to psychological guidance to avoid the occurrence of anxiety and depression. Give laxative medication and eat more easily digestible and absorbable food to avoid constipation. Monitor the strength and sensation of the limbs. If the strength of the limbs decreases or the sensation level increases, it does not exclude the progression of the disease and should be alerted. Pay attention to supplemental nutrition and adhere to rehabilitation training to avoid aggravation of the disease. Long-term effective rehabilitation training will help patients repair their neurological dysfunction. After discharge from the hospital, pay attention to the changes in limb strength, sensory impairment, and the presence of muscle atrophy. Fortunately, the patient’s condition was not further aggravated after early treatment, and he was able to walk short distances with the help of braces at a later stage, so that the limb function could be improved to a certain extent.
V. Personal insight
Viral myelitis is a serious and acute disease, and if it is not treated early and actively, it may leave sequelae, seriously affecting the life of the patient and increasing the burden of the family. It is important to develop good living habits and improve immunity in general. Family members should actively pay attention to the changes in the patient’s condition, care about helping the patient, give more understanding, let the patient face the treatment with a positive and good attitude, at the same time should do a good job of family care and nutritional support, and assist the patient to carry out active rehabilitation training, which will help the patient to recover as soon as possible. Patients should also listen to medical advice and adhere to rehabilitation training to avoid muscle atrophy in the later stages of the limb.