What are your thoughts about possible diagnoses and what type of diagnostic tests for the patient?

Question

A 65yr old male construction worker comes to the Emergency Department alone. His main complaint is incontinence of both bladder and bowel of 10 hrs duration. He also complains of right lumbar pain and paresthesia of medial femoral regions bilaterally. He appears to have muscle weakness in that his gait is altered. He is not febrile. He was released from the hospital 3 weeks ago after having been admitted for COVID-19 during which time he received oxygen and other supportive treatments and was released after 4 days. Past medical history is otherwise unremarkable.

1)What are your thoughts about possible diagnoses aka differential diagnosis?

2)What are the next steps you would want to take to narrow the diagnosis? What questions do you want to ask the patient or diagnostic tests do you want to take?

Answer 1

The most pressing concern here is cauda equina syndrome which is the result of compression of the nerve roots below the end of the spinal cord at L1. Symptoms of urinary retention, bowel dysfunction and saddle anesthesia are typical. Anatomic compression by a herniated disc is the most common cause, however compression may also be due to tumor, hematoma or spinal stenosis. Rarely, Differential diagnosis includes spinal cord injury, conus medularis syndrome, transverse myelitis, multiple sclerosis, HIV associated myelopathy and synringomelia.

Patient should be questioned about trauma, fever, h/o cancer, h/o HIV, sexual dysfunction. Did he receive steroid for COVID which may predispose him infection, including epidural access. COVID-19 has been reported to cause rare cases of transverse myelitis with similar presentation to this patient.

This is a medical emergency and MRI should be done immediately.