Weakness is a vague symptoms and one must make sure whether it refers to neurological weakness – paresis or non-neurological problems. Alternately, it can also just be a matter of perception- equating thinness to weakness. In such cases, parents would need to be counselled. In this article, Dr. YK Amdekar describes 8 cases with general weakness as a prominent symptom. He explains evaluation of each and reveals the final diagnosis and treatment approach.

To read other originals by Dr. YK Amdekar, click here.

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Case-based discussions

Case 1

A 10-year-old child presented with generalised weakness over the last two weeks. There were no other symptoms. On direct questioning, this child had stopped going out to play over the last few months though for no apparent reason. He would prefer to be sedentary. There is no history of palpitation or breathlessness or polyuria, polydipsia, and polyphagia. Parents had not noticed any significant pallor. It is obvious that this problem has existed for several months though may have been aggravated over the last two weeks and hence presented now.

This teaches us how important it is to make sure whether given symptoms exist only for reported duration or subtle symptoms existed in the recent past. This history suggests that this child has been getting progressively tired over months. Absence or palpitation, breathlessness and symptoms of diabetes rules out chronic lung, heart conditions and chronic anaemia. So we have no clue to diagnosis on history. In such a situation, one must consider conditions with subtle symptoms or signs that are easily overlooked.

Physical examination showed no abnormality on casual cursory examination but on detailed observation, his respiratory rate was 30 per minute at rest and it was certainly abnormal. Further oxygen saturation at rest was 92%; that meant he was hypoxic. Though he was apparently comfortable. Chronic hypoxia may often be tolerated by patients as they get adapted to it. Polycythemia often compensates mild chronic hypoxia.

This finding is in favour of chornic interstitial lung disease. Investigations showed Hb 15 gm%, CBC otherwise normal, chest X-ray normal, HRCT showed evidence of interstitial lung disease. Thus, diagnosis of chronic interstitial lung disease was confirmed. Plain chest X-ray is often normal in such a condition and so also cursory physical examination. This case emphasises the need for thorough physical examination.

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Case 2

A 15-year-old child presented with generalised weakness and on direct questioning he reported tiredness that was gradually increasing. Apparently, he had no other symptoms except mild cough. At the age of 6 years, he had suffered from rheumatic fever with arthritis, from which he had recovered completely.

Gradually increasing tiredness suggests slowly progressive disorder. With the background of rheumatic fever in the past, one may consider heart condition such as valvular damage. Tiredness in this child indicates deficient oxygen supply to muscles as a result of cardiac disease. It denotes pulmonary venous congestion due to back pressure from the left side of the heart. It may favour diagnosis of mitral stenosis. Mitral regurgitation may have been more symptomatic with breathlessness.

Physical examination revealed heart rate 92/min at rest, respiratory rate 27/min (both mildly increased), no obvious cardiomegaly but loud first heart sound and mid-diastolic murmur at mitral area. This suggests diagnosis of rheumatic mitral stenosis. Echocardiogram confirmed diagnosis of mitral stenosis. This child needs surgical intervention.

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Case 3

A 4-year-old child presented with generalised weakness for the last four months that made him not participate in play activities. Apparently, there were no other symptoms except mild cough. On detailed questioning, he would feel tired after playing for a few minutes and would rest in between such activities. It suggested slowly worsening tiredness over several months. It could be either lung or heart disease.

If it is a heart disease, it is unlikely to be congenital heart defect because he was normal during the first three years of life. Rheumatic heart disease also can be ruled out as he has been too young to have suffered from damage to heart as a result of rheumatic fever. However, other types of heart diseases such as primary myocardial or pericardial conditions cannot be ruled out. Chronic interstitial lung disease is a possibility, as interstitial lung diseases have different aetiologies including damage due to previous viral infections and also due to environmental exposure to toxic substances or pollutants.

Physical examination showed heart rate 104/min and respiratory rate of 28/min (both on the higher side), precordial pulsations, mild cardiomegaly, soft systolic murmur at mitral area not conducted with normal heart sounds. Chest examination revealed few crepitations at the base of the lungs. This suggests probable primary myocardial disease.

Echocardiogram confirmed diagnosis of cardiomyopathy. Aetiology of such a disease is not easy to correlate as it may result from events that have occurred in the past such as viral infection. Further investigations are necessary to rule out metabolic or storage disorders.

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Case 4

An 8-year-old child presented with generalised weakness and tiredness over last two months that was gradually increasing. On direct questioning, he reported mild fever on and off during this period. But, it did not disturb him and so was ignored. There were no other symptoms. Mild fever on and off suggests probable infection that has affected either the lungs or the heart. Absence of cough almost rules out infective lung disease.

Valvular or myocardial diseases do not present with low grade long duration fever but pericardial affection is likely. It may be in the form of mild pericardial effusion or constrictive pericarditis. Mild pericardial effusion may not be symptomatic and if fluid accumulation increases, it may lead to breathlessness. However, constrictive pericarditis may deteriorate slowly as fibrosis develops slowly in chronic infection such as tuberculosis. So one must look for evidence of constrictive pericarditis in this child.

Physical examination showed mild tachycardia and tachypnoea but no other cardiac findings. However,  the liver was enlarged and firm, but not tender and the neck veins were engorged without hepatojugular reflux. This suggests superior and inferior vena caval obstruction and so diagnosis of constrictive pericarditis due to tuberculosis was considered. Echocardiogram can confirm such a diagnosis by demonstrating restriction of movement of heart that are hampered by pericardial fibrosis.

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Case 5

A 4-year-old child presented with generalised weakness and reluctance to participate in play activities over the last six months. It was gradually increasing to an extent that he would refuse to go out to play. Earlier, he used to be a very active child. There were no other symptoms. Gradually increasing tiredness indicates slowly worsening oxygenation either due to chronic lung or heart disease.

Absence of cough rules out lung disease as well heart disease with pulmonary congestion. So it may be due to heart condition with pulmonary oligemia – less of blood flowing through lungs resulting in lack of oxygen. However, such a child should develop cyanosis but if pulmonary obstruction is mild, cyanosis may not be noticed by parents. Though on direct questioning, parents may reveal probable cyanosis seen on crying. However, it can be easily overlooked.

Physical examination showed mild clubbing of nails that is suggestive of chronic hypoxia, systolic murmur at pulmonary area without cardiomegaly or cardiac failure. This is in favour of Pink Fallot’s Tetralogy. Echocardiogram confirmed the diagnosis. He would need surgical correction.

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Case 6

A 6-year-old child presented with a slowly progressive tired feeling over the last 6 months. He was normal prior to onset of present symptom and was very active. Initially, he would run about but would need to rest – it was unusual for him though was ignored. When this problem increased over time to an extent that he would refuse to go out to play, parents sought medical advice.

On direct questioning, he had developed cough over the previous two months that was also slowly worsening. It suggests slowly worsening tiredness but with worsening cough as well. However, cough was not a symptom in the initial few months. It suggests probable space occupying lesion in the chest, now compressing over airways leading to increasing cough.

Physical examination showed impaired note on percussion on the right anterior side of the chest but it did not correlate with either lobes of lungs or pleura. Physical findings in lung lesions are restricted to the surface area of lobes of lungs. It means the right upper lobe lesion has findings only in the upper half of the chest anteriorly and the right middle lobe only in the lower half of the chest anteriorly. The lower lobe is represented only posteriorly.

Physical findings in pleural disease are seen below a particular intercostal space but all over the chest anteriorly, laterally and posteriorly. Percussion findings in this child did not suggest either lobar or pleural pattern. It denotes probability of mediastinal mass in the chest. Chest x-ray confirmed large mass in anterior mediastinum and was proved to be benign. It was surgically removed.

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Case 7

A 10-year-old child presented with generalised weakness and tiredness for one week. He was very active prior to the onset of this symptom and in fact used to attend coaching for tennis. A week prior, he felt tired while playing though the coach insisted he continue to play and so the next day he refused to go to play. Initially, the parents thought he was just being stubborn. But when his problem persisted, they visited a doctor.

It was only on direct questioning that polyuria, polydipsia and polyphagia was apparent and so a diagnosis of diabetes mellitus was confirmed. He would have come in with diabetic ketoacidosis and unconsciousness within the next few days had he been further ignored.

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Case 8

A 2-year-old child was brought by the mother complaining of generalised weakness since the age of one year. According to the mother, this child was doing well until the age of one year. He had grown well and weighed 10.5 kg at one year; his food intake was good. But thereafter he started making a fuss about eating and despite trying various methods and tonics, there was no improvement. He had gained just 1.5 kg through the entire second year. So she was worried about his generalised weakness.

On direct questioning, the mother reported that he maintained his activity level and there were no physical complaints. An active child almost rules out any significant pathology. Physical examination showed a happy and active child, weight 11.5 kg, length 87 cms and there was no abnormality detected. So, this child was completely normal. This mother was interpreting “poor” intake of food and “poor” weight gain during the second year as weakness. She had to be counselled rather than the child needing any investigations or treatment. So, the mother had to be managed.

Health status is better judged by activity level and growth by length/height and not by weight. Weight gain is variable in normal healthy children and all that we need to ensure is no weight loss and some weight gain over months. Weight gain in a normal child during the second year is one third of what he gained in the first year while length gain is half of what he gained in the first year. Thus, every normal child looks thin during the second year as compared to the first year due to differential gain in length and weight. This is often reported by mothers as weakness. What doctors must learn is to counsel well rather than prescribe tonics or order some tests.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.