Uncommon presentation of a common disorder
A 30-year-old male, working as a tailor in an export company, presented to us with complaints of stiffness in lower back region for one and a half months duration followed by stiffness of limbs and slurring of speech for 1 month duration. The patient was apparently normal 2 months back, when he developed fever which was intermittent, high grade, and associated with chills and rigors. He had generalized myalgia. There was no history of headache or vomiting. Though he became afebrile after 5 days, he continued to have myalgia and general malaise. In addition he developed pain over the lower back region, which increased in intensity on exertion. He went back to his job after 10 days but had difficulty carrying out his work due to the low back pain. About 3 weeks later, he noticed stiffness over the lower back region, which restricted his activities. He could not bend down and also had difficulty in turning around. The stiffness gradually spread to involve the entire trunk and neck in the next 15 days. Two weeks later, the patient developed swelling of the face, right upper limb, and right lower limb. He also had diffuse pain and stiffness over the same regions for which he had consulted a local practitioner of alternative medicine. The swelling gradually subsided but the pain and stiffness persisted. Over the next 5 days, the patient developed pain and stiffness of the left upper limb and left lower limb also, but of a lesser intensity.\nThe patient noticed progressive increase in stiffness of neck, trunk, and limbs (Right > Left [R > L]) on walking about 20–30 meters, after which he was unable to take another step. He had to stop for 10 minutes before resuming to walk. He gave history of falling down en bloc backwards (4–5 episodes) when he had tried to walk during the periods of severe stiffness. The stiffness was moderate at rest. He had severe restriction of neck and trunk movements. He had difficulty in using his upper and lower limbs (R > L) for all daily activities due to the severe stiffness. He developed stiffness of hands while mixing food and brushing teeth. He had stiffness of jaw muscles on prolonged chewing. He developed stiffness of facial muscles after speaking for some time causing reduction in voice along with slowness and slurring of speech.\nThe patient's symptoms were initially progressive but had been static later on. He gave no history of precipitation of symptoms by auditory or tactile stimuli. He had no thinning of limbs or muscle twitchings or other involuntary movements of limbs. He had no sensory disturbances or higher function disturbances or cranial nerve involvement or bladder or bowel disturbances. He had no difficulty in releasing finger grip, no aggravation of symptoms by cold, no abnormal posturing of limbs, no lhermitte's symptom, no shooting pain in the limbs, no history of altered color of urine or reduced urine output, no breathing disturbances, no cough with expectoration or chest pain, no head or spinal injuries, and no drug or toxin intake. Past/personal/family history—uneventful