Case Presentation: A 56-year-old woman with a history of gastric bypass surgery six years prior, vitamin B12 deficiency, latent TB, and recent bilateral granulomatous panuveitis of unclear etiology one year prior (treated empirically with TMP/SMX for possible toxoplasmosis) presented to the hospital with falls at home. On further history, she endorsed four months of gradually worsening lower extremity weakness, tingling, and urinary retention, and one month of worsening constipation and back pain. She had seen multiple providers for these symptoms, and had undergone urodynamic testing that showed impaired detrusor function and incomplete bladder emptying. At the time of admission she had minimal urinary output, weekly bowel movements, and was having difficulty ambulating with a cane. Her social history was notable for emigrating from the Dominican Republic 15 years ago with ongoing annual visits.Vital signs were normal on presentation. Physical exam showed moderate weakness in left greater than right lower extremities, impaired sensation below the knees, and diffuse hyperreflexia in upper greater than lower extremities. Ankle jerks were absent. Gait was wide-based and unsteady. An extensive workup was performed and serum labs were unremarkable, including normal vitamin levels and inflammatory markers. MRI of the brain and spinal cord was normal. On lumbar puncture there were 56 WBCs, 90% of which were lymphocytes. Given the patient’s demographics and these CSF findings, HTLV-1/2 antibodies were sent and returned positive, consistent with a diagnosis of HTLV-1 associated myelopathy/tropical spastic paraparesis (HAM/TSP). The patient received pulse dose steroids and baclofen with partial improvement of her symptoms.
Discussion: HTLV-1 infects an estimated 10 to 20 million people worldwide and is endemic in many regions including Japan, the Caribbean, South America, the Middle East, and parts of Africa. The seroprevalence in these areas ranges from 3 to 30%, and the virus can be transmitted vertically, sexually, and parenterally. The virus is often asymptomatic, but in 5% of infected individuals HTLV-1 causes serious disease including adult T-cell leukemia/lymphoma, HAM/TSP, and uveitis, with disease onset ranging from 4 months to 30 years after infection. Our patient’s uveitis one year prior to presentation might have also been caused by the virus. HAM/TSP presents as chronically progressive spastic paraparesis mostly affecting the lower extremities with associated back pain, bladder/bowel and sexual dysfunction. Diagnosis is often delayed due to insidious onset and limited familiarity with the clinical entity among healthcare professionals. Research into treatments is ongoing though unfortunately disease-modifying interventions remain limited, and many patients eventually become wheelchair-bound.
Conclusions: Weakness is a common complaint amongst patients hospitalized in general medical wards. Physicians should consider HAM/TSP in patients from endemic areas who present with slowly progressive lower extremity weakness and spasticity, bowel/bladder symptoms, and inflammatory CSF findings.