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Tropical Spastic Paraparesis in Labor and Delivery: Case Report
Abstract Number: 236
Abstract Type: Case Report/Case Series
Introduction: Tropical spastic paraparesis (TSP) is a viral immune-mediated disorder of the spinal cord and occurs mostly in patients from countries near the equator.
It presents as slowly progressive spasticity, weakness and pain of the legs, paresthesias and bladder dysfunction. It rarely involves the arms. It is also known as HTLV1 associated myelopathy but can be seronegative.1 There are no reports in the literature on the safety of epidurals in TSP, thus patient consent for a case report was obtained.
Case Report: A 36 year old G1P0 from Ethiopia was seen in consult by anesthesia at 37 weeks because she had an undiagnosed spastic syndrome. She worried that she could not push the baby out. She had slowly increasing weakness and painful spasms mostly in the right leg since17 years old. She had mild pain and weakness in the right arm and low back pain off and on. She was seen by a neurologist a few years ago and tested to rule out hereditary spastic paraparesis. She had a normal brain MRI and lumbar spine MRI showed mild disc bulging at L4/5 and L5/S1. Neurological exam revealed pathologically increased reflexes, bilateral extensor plantar responses, mild pyramidal pattern weakness in the right leg and spastic gait.
Neurology consultation diagnosed possible TSP. HTLV1/2 and HIV blood tests were sent. After discussion with colleagues and comparison of TSP to similar disorders, it was decided that epidural was not contraindicated. Patient was informed that due to the progressive nature of her spasticity and weakness, there was concern that she could worsen functionally postpartum (with or without epidural). Options for pain management in labor were discussed. She was reassured that she could likely deliver vaginally based on case reports.2
The patient came in a couple of weeks later in labor and requested an epidural, which she received with no complications and delivered the baby vaginally with vacuum assistance. TSP-related blood tests were negative. On follow up with the neurologist a couple of months postpartum, the rate of worsening of her spasticity had not increased.
Discussion: We describe the first case report of epidural analgesia for labor and delivery in a patient with suspected seronegative TSP. In this case there was concern that any worsening of neurological state could be attributed to the epidural. There was also concern that added weakness from epidural motor block would compromise pushing, however, the epidural could ease the painful spasms and actually help pushing. We decided to proceed with the epidural because of similarity in clinical picture between TSP and MS. Although TSP is slowly progressive rather than relapsing and remitting like most cases of MS, spasticity in both results from disturbance of corticospinal tract pathways or myelopathy. There is some controversy with spinal anesthesia in MS but epidural is considered safe.
1 Arq Neuropsiquiatr.2008;66: 695-697
2 Arch Gynecolo Obstet.2003;268: