Question

Here is a challenge for some of you out there!



An 18 year old girl presents with paresthesia of both lower limbs, which progressed into weakness and difficulty in walking over a period of 3 days.

There was no bladder or bowel incontinence, or a history of trauma.

She experienced an upper respiratory tract infection 3 weeks earlier. Her medical history is unremarkable.

Exam:
Afebrile
Pulse: 104 bpm, regular
BPL 110/70

Exam shows no abnormalities in heart lungs abdomen.

CNS:
Lower limbs:
Motor System:
No fasciculations or wasting
Generalized hypotonia
Grade 2/5 power bilaterally, in all muscle

Answer 1

*muscle groups
Knee and ankle jerks absent
Flexor plantar responses bilaterally
Sensation: no impairment
Coordination: unable to assess due to weakness
Gait: cannot walk

Cranial nerves & upper limbs: no abnormalities.

Answer 2

What tests would you perform? (choose all that apply)

A. Stool cultures for polio-virus
B. Lumbar puncture
C. Nerve conduction studies
D. Serum electrolytes.

Answer 3

Depending on your diagnosis what would be the correct management?
A. Antibiotics
B. IV Immunoglobulin
C. Corticosteriods
D. ICU care

Answer 4

I have answers just post what you think it may be and I will correct!

Answer 5

@Abhisar

Answer 6

at first glance it seems like stool sample for polio could be an option, as for treatment, depending on how fast it is progressing it can range from B to C, if it is indeed polio infection IV immunoglobulin introduction would help to deal with post-polio effects, corticosteroids could help reduce inflammation during disease, ICU if the case is out of control and needs to be monitored closely
Critical thinking is vital here tho. It could very well not be polio and doing lumber puncture for some other possible cases would too be an option at least just to eliminate worst case scenarios.

Answer 7

A stool cultures test for polio-virus is not needed

Lumbar puncture - yes
Nerve conduction studies - yes
Serum Electrolytes - yes

Answer 8

so what is the diagnosis?

Answer 9

Would you like to know the results of the tests first?

Answer 10

ofc without that how can we diagnose even

Answer 11

We can't but I had figured that maybe you had a diagnosis

Answer 12

i have a hunch but not confident since im far from becoming a doc lol

Answer 13

Lumbar Puncture:

Appearance: clear
Polymorphs: nil (<5)
Gram stain: negative
Glucose: 70mg/dL (50-80)
Protein: 50 mg/dL (15 mg/dL (15 mg/d1 - 60 mg/d1)

Answer 14

Nerve conduction studies of both lower limbs are normal.

Answer 15

Serum Electorlytes:

Na+: 137 mEq/1 (135 - 145)
K+: 4.2mEq/1 (3.5 - 5.5)
C1-: 101 mEq/1 (97 - 105)

Answer 16

These are the test results any ideas now?

Answer 17

The differential diagnosis of acute lower limb weakness is extremely broad, encompassing lesions from the brainstem, to the spinal cord, peripheral nerves, neuromuscular junction (NMJ), and muscles.

Answer 18

it doesnt look like there is infection from these results or maybe im not educated enough to recognize something from these results

Answer 19

However, examination shows the weakness to be flaccid in nature - this signifies a lower motor neuron (LMN) lesion, and localizes it to the neuromuscular arc (i.e. from the anterior horn cells to the nerves, NMJ and muscles).

Answer 20

that is what i thought
but what caused it, thats what i was curious about

Answer 21

i could tell that it was LMN from the fact that DTRs are absent from what you said, but like, what happened? i mean u said there was no trauma, it doesnt look like there is infection, is it not known?

Answer 22

In addition, the history of numbness (i.e. a sensory disturbance) excludes pure diseases of the anterior horn cells (such as motor neurone disease or poliomyelitis), of the NMJ (such as myasthenia gravis) and of the muscle (such as polymyositis or channelopathies).

However, note the lack of objective sensory findings; this allows us to 'short-circuit' the diagnostic process, as the combination of sensory symptoms without corresponding signs is almost characteristic of Guillain–Barré syndrome (GBS).

Answer 23

This prospective diagnosis is further supported by the symmetric and progressive nature of the weakness, and absence of a clear-cut motor level; the history of a preceding respiratory tract infection lends further credence.

Answer 24

why didnt we test for white blood cells in CSF?

Answer 25

It is important to keep in mind that a few other diseases can present in this manner - most particularly hypokalemia, toxic neuropathies (i.e. due to alcohol, lead or mercury), acute porphyria and tick paralysis. However, there is no evidence of electrolyte disturbances; the remaining conditions are comparatively rare, and should probably be considered only if GBS is definitively excluded.

Answer 26

Cerebrospinal fluid (CSF) analysis and nerve conduction studies (NCS) should be performed, as these may demonstrate changes characteristic of GBS. However, the negative results here do not exclude the disease, as these investigations are often normal or equivocal in the first week.

Answer 27

This emphasizes the importance of being astute enough to clinically diagnose GBS, as the outcome is directly proportionate to the timeliness of diagnosis and treatment.

Answer 28

GBS is a life threatening condition; she needs immediate treatment with IV Immunoglobulins; close observation and management in an intensive care setting should be considered.

There is no role for corticosteroids or IV antibiotics in her current management.

Stool cultures are not needed here (but would have been considered if poliomyelitis were suspected).

Answer 29

i get it
one question tho
if it is GBS, which is practically autoimmune disease, wont we be able to find immune cells in CSF sample? I assumed we could

Answer 30

Investigations may be performed to support the clinical diagnosis; these include CSF analysis and electrodiagnostic studies.

CSF analysis characteristically shows albuminocytologic dissociation (elevated protein levels with normal cell counts). Nerve conduction studies may show features suggestive of demyelination and/or axonal degeneration.

An important point to keep in mind is that in the first week, only half of patients show albuminocytologic dissociation, while NCS studies may be normal or equivocal. As prompt treatment is essential for a good outcome, the importance of clinical diagnosis cannot be underemphasized.

Antibody assays may be of use in patients with an atypical presentation (for example, Antiganglioside antibodies in MFS); however, these have limited clinical utility.

Answer 31

There are two key aspects to the management of GBS: immunotherapy to halt disease progression, and monitoring and supportive care to prevent and treat associated complications.

Both plasmapheresis and IV immunoglobulin (IVIg) are equally effective immunomodulatory therapies; however, plasma exchange is both more complex to administer and associated with more complications, making IVIg preferable in most cases.

Answer 32

Did I answer your question well enough?

Answer 33

Also you seem to know about this do you have training within emergency medicine?

Answer 34

Are you a med student?

Answer 35

No I currently work at Huggins Hospital as an Emergency Care Physician.

Answer 36

My friend told me about this site and I wanted to see exactly what it was like so I joined it and have helped and seen what the common level of knowledge is in the community.

Answer 37

This was a question I came up with for training I thought I would post it here and see what happens!

Answer 38

i see, it was an interesting case, though i didnt get a direct answer :3
this case, are these study cases or your case report?

Answer 39

It was a rapid care question that I used for the Med students.

Answer 40

o i see, so thats why it looked like copy pasting, i thought u got it somewhere from internet, well thats cool. Learnt something

Answer 41

Nope just figure I would take it off my report that I made.

Answer 42

im second year med, so i dont really know much, and there are sadly not much med ppl in this website

Answer 43

You will get there! Do you enjoy it so far and if so what specialty are you looking at?

Answer 44

I might post more of these types of questions I will tag you in the future.

Answer 45

Practice is always a good thing the best way to learn is through repetition.

Answer 46

well, medicine i guess is part of me since i have enthusiasm in it. Neuro is cool, its hard but its extremely cool. Cardio is also fascinating. Im actually into oncology, but after seeing these two im still thinking

Answer 47

Ofc, i like such case reports, they give me an idea about what im learning that is

Answer 48

Oncology is cool to though!

Answer 49

immune system is also real interesting, im specifically interesting in cancer immunotherapy

Answer 50

Cancer immunotherapy is a good gig too! Ok well I actually have to go now but good job today!

Answer 51

Thanks for the case report! It was interesting :D

Answer 52

No problem more coming in the future!

Answer 53

will be looking forward to it

Answer 54

I just became a fan so that I can tell when you are online.

Answer 55

do you have any cardio or pulmonary cases? id love to see those

Answer 56

in near future that is :3 the nearer the better since i have exam on those soon lol

Answer 57

Ok I will post one of those!

Answer 58

Goodbye!

Answer 59

Thanks :3
See ya!