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Dr Pratyush Chaudhuri

Supported by Nirmal ClinicsScience comes first

Neuro Clinics 58

Hypo reflexia – Deep tendon reflexes

Case 1

• 35years old female patient was admitted to the hospital following

• Onset of weakness in both lower limbs • Inability to walk• Unable to pass urine• Tingling paraesthesia in both lower limb since 2

hrs• Mid level back pain

• History of fever 14 days earlier lasted for 2 days

• Hypotonic lower limb• Power 2/5in both lower limb• Hyporeflexic• Sensory level at D8 level

• Flaccid bladder

• What is the possible etiology

• What will be your diagnosis if the reflex was – hyper-reflexia

Case 2

• 56 yrs old male k/c/o Diabetes mellitus• presented with Pain in the low back since

3 years• Increases while lying in supine position• Associated with radiating pain on the left

lower limb

• SLR on the left restricted to 30 degree on the left side

• Paraspinal tenderness on the left lowerback

• Hyporeflexia in the left ankle!• Radiating lancenating pain• BP 150/100mmHg

• What have you thought of?

• What is the next information you will ask for?

• What would you think of if the reflexes were hyper-reflexic?

• Diagnosis:Left lumbar radiculopathy due to possible

degenerative disc disease with early motor deficit.

Case 3

• 42 yrs old male who was diagnosed as a case of hypothyroidism 2 yrs earlier

• Presented with • Increased sleep and lathergy• Fever since 2 days• Burning micturation

• He was taking his thyroid hormone regularly.

Physical examination• Normothermic • Tachycardia, BP 160/100mmHg• Peripheral oedema• Central obesity• Hyporeflexic all over

• Any diagnosis in mind?

• Do you want to ask for any other clinical finding?

• Woltmann’s sign of hypothyroidism

• Delayed relaxation phase

Other causes of woltmann’s sign

• Advanced age • Anorexia nervosa• Diabetes Mellitus• Drugs like quinidine, IV dextrose, IN potassium.• Hypothermia• Peripheral arterial disease• Pernicious anemia • sarcoidosis

• What would you think of if the reflex was to be brisk?

Causes of intermittent hyporeflexia

• Normal variant in some children • Spinal cord compression • Spinal cord infarction • Disc herniation • Transverse Myelitis • Occult spina bifida (type of Spina bifida) • Neuropathy due to diabetes mellitus • Neuropathy due to giant axonal neuropathy • Chronic inflammatory demyelinating polyneuropathy • Tumor affecting nerves • Trisomy 21 • Edward's syndrome • Spinal muscular atrophy • Charcot-Marie-Tooth disease • Hypothyroidism • Hypokalemia • Hypoparathyroidism

Case 4

• 32yrs old female• Presented with generalised bodyache• Difficulty in getting up from the sitting

position since 3 months• Loss of confidence in walking• K/c/o hypercholesterolemia on clofibrate

and atorvastatin.• No other illness

• Examination reveals• Normal vitals• Weakness in both lower limbs with power

in the hip jt 3/5 and knee 4/5 bilateral• Difficulty in getting up from squatting

position or standing on the toes• Hyporeflexic• No sensory deficit

• Spot diagnosis??

Drugs that cause myopathy

• Painless– With out neuropathy- corticosteroids– With neuropathy- colchicine , chloroquine,

hydroxychloroquin– Myasthenic syndrome- D penicillamine,antibiotics and

betablockers

• Painful– With myosistis- Zidovudine, D

Penicillamine,cemetidine– Without polymyosistis- clofibrate, statin, cyclosporin

• Eosinophilia –myalgia syndrome – L-tryptophan