Clinical Case 1
Alec Small, D.O.
Paul Ehlers, M.D.
Just an average day at work...
CC: Numbness and Tingling
Triage Note: Sent from PCP for numbness & tingling since last saturday ( 1 week). Seen at OSH for same and discharged
HPI
38yoM with no medical history presents to the ED for numbness and tingling. Pt states that for about 1 week he has had numbness and tingling throughout his upper and lower extremities. He deny and pain, trauma, urinary or bowel symptoms, chest pain, nausea, vomiting, abdominal pain, fevers, chills. He admits that he is a daily drinker for about 10 years consuming approximately half a pint a day. Recently ceased use 16 days ago. No history of withdraw. Denies vision changes, headaches. States towards end of day he feels weaker and has difficulty using his phone and holding his keys. Says 2 weeks ago he went to his PCP for sore throat which resolved. He has remote history of IV drug use. Denies back pain, hx cancer, steroid use, incontinence/retention, saddle anesthesia.
ROS: Negative except for HPI
Physical Exam
GEN: Well appearing, NAD
HEENT: NC, AT, MMM, EOMI, Clear conjunctiva, Oropharynx clear
Neck: Supple, no stiffness or restricted ROM
HEART: RRR, Normal S1/2
LUNGS: CTAB, Moving air well, no wheezing
ABD: Soft, nondistended, nontender
BACK: No midline tenderness no obvious deformity
EXTREMITIES: No edema, deformit, DP/radial pulses +2
SKIN: No rashes, warm
NEURO: A&OX4, moves all extremities, CN grossly intact, intention tremor of US, when raising b/l UE shoulders go to his ears, MS 5/5 in b/l UE and LE. Grip strength 5/5, No facial droop, Speaks in clear sentences. Gait…
Click to view gait
Basic Labs
LFTs within normal limits
Imaging
Let's solve this mystery!
CSF Studies
CSF MS stuff: Negative
CSF Cultures: Negative
MRI: Negative
Click to view diagnosis
Guillian-Barré Syndrome (GBS)
Post-infection inflammatory neuropathy
Most common cause of acute generalized paralysis since essential elimination of polio
Often misdiagnosed
Onset from 3 days to 6 week after infection
Common symptoms include; paresthesias, limb weakness, back pain, altered gait
Respiratory depression and cranial neuropathy often occur later
Diagnosis & Treatment
Confirmatory workup involves an LP
Imaging is often ordered with nerve conduction
As always; ABCs
No use for steroids; use IVIG or plasma exchange
Patients should go to ICU/Neuro ward
Prognosis & Outcome
The clinical course and outcomes of GBS are highly variable
Mortality varies; some populations are more at risk
Death from disease usually >30 days
Often with residual deficits
GBS disability score used as predictor
Our patient
-Hospitalized for about a week
-Not terribly complicated hospital course
-Follows in outpatient setting regularly
-Living a productive life
References
van den Berg, B., Walgaard, C., Drenthen, J. et al. Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis. Nat Rev Neurol 10, 469–482 (2014)
Head VA, Wakerley BR. Guillain-Barré syndrome in general practice: clinical features suggestive of early diagnosis. Br J Gen Pract. 2016;66(645):218-219
Noto, A., & Marcolini, E. (2014). Select Topics in Neurocritical Care. Emergency Medicine Clinics of North America, 32(4), 927-938.
Natesan S. Guillain-Barré syndrome - third time's the charm. emDOCs.net - Emergency Medicine Education. http://www.emdocs.net/guillain-barre-syndrome-third-times-charm/. Published May 22, 2017.