What is the diagnosis for a 45-year-old female with abdominal pain, constipation, known hyperthyroidism, anemia (low hemoglobin), leukocytosis (raised white blood cell count), and sudden paralysis below the waist?

Acute Spinal Cord Compression from Intra-abdominal Malignancy

This patient requires immediate CT abdomen/pelvis with contrast and urgent MRI spine with contrast to identify spinal cord compression, which is the most likely cause of sudden paralysis below the waist in the setting of abdominal pain, anemia, and leukocytosis. 1

Critical Immediate Actions

Emergent spinal imaging must not be delayed - sudden paralysis below the waist represents a neurological emergency requiring immediate MRI spine with contrast to identify cord compression, epidural abscess, or metastatic disease. 1 The combination of:

• Abdominal symptoms (pain, constipation)
• Constitutional symptoms (anemia suggesting chronic blood loss or malignancy)
• Leukocytosis (suggesting infection or malignancy)
• Acute neurological deficit (paralysis below waist)

...points toward either metastatic spinal cord compression from an occult abdominal malignancy or epidural abscess with intra-abdominal source. 1

Diagnostic Workup Priority

First-Line Imaging (Stat)

• MRI spine with gadolinium contrast is mandatory to evaluate for cord compression, epidural abscess, or vertebral metastases causing acute paraplegia. 1
• CT abdomen/pelvis with IV contrast should be obtained simultaneously to identify the primary abdominal pathology - potential sources include colorectal malignancy, lymphoma, or intra-abdominal abscess. 1

Laboratory Evaluation

The existing findings require expansion:

• Complete blood count with differential - leukocytosis may indicate infection (abscess) versus leukemoid reaction from malignancy. 1
• Inflammatory markers (CRP, procalcitonin, lactate) help differentiate infectious from malignant processes. 1
• Serum calcium - hypercalcemia can cause constipation and occurs with malignancy. 1
• Lactate dehydrogenase (LDH) - elevated in lymphoma and hemolysis. 1

Hyperthyroidism Considerations

While hyperthyroidism can cause:

• Anemia (10-20% of thyrotoxic patients develop anemia, including autoimmune hemolytic anemia). 2
• Leukocytosis (normochromic normocytic anemia and leukocytosis occur in 60-67% of cases). 1
• Hypokalemic periodic paralysis (causing symmetric limb weakness). 3

However, thyrotoxic periodic paralysis does NOT cause isolated paralysis below the waist - it presents with symmetric proximal muscle weakness in all four limbs with preserved sensation. 3 The sudden onset of paraplegia indicates structural spinal pathology requiring immediate imaging.

Most Likely Diagnoses

Primary Consideration: Metastatic Spinal Cord Compression

• Colorectal malignancy with vertebral metastases is highly probable given the age (45 years), chronic constipation, abdominal pain, anemia (chronic GI blood loss), and leukocytosis. 4
• The American College of Gastroenterology states that combination of weight loss (implied by chronic symptoms) and microcytic anemia constitutes alarm features requiring exclusion of colorectal cancer, even in younger patients. 4
• Colonoscopy is mandatory despite age when alarm features are present. 4

Alternative Consideration: Epidural Abscess

• Intra-abdominal infection (diverticular abscess, appendiceal abscess) can seed hematogenously to cause spinal epidural abscess. 1
• Leukocytosis, fever, and elevated inflammatory markers support this diagnosis. 1

Less Likely: Lymphoma

• Rosai-Dorfman disease or lymphoma can present with abdominal pain, constipation, anemia (67% of cases), leukocytosis (60%), and spinal involvement causing cord compression. 1
• However, this is less common than metastatic carcinoma in this age group. 1

Critical Pitfalls to Avoid

• Do not attribute paralysis to thyrotoxic periodic paralysis - this condition causes symmetric limb weakness, not isolated lower extremity paralysis, and does not cause sensory level. 3
• Do not delay spinal imaging for abdominal workup - spinal cord compression is a time-sensitive emergency where outcomes depend on duration of symptoms before decompression. 1
• Do not assume anemia is solely from hyperthyroidism - microcytic anemia should not be attributed to thyroid disease alone without excluding GI pathology, particularly malignancy. 4
• Do not perform colonoscopy before addressing the acute neurological emergency - while colonoscopy is indicated, spinal cord decompression takes precedence. 4

Immediate Management Algorithm

1. Stat neurosurgical consultation for potential emergent decompression. 1
2. High-dose IV dexamethasone (10mg loading dose) if spinal cord compression confirmed, to reduce edema. 1
3. Broad-spectrum IV antibiotics if epidural abscess suspected (fever, elevated procalcitonin). 1
4. Correct electrolytes - check potassium given hyperthyroidism history, though unlikely causative. 3
5. Once stabilized: proceed with colonoscopy and upper endoscopy to identify GI source of anemia and evaluate for malignancy. 4