OPINION
FROM THE BLOGOSPHERE
BAFFLING NEUROLOGY Pathology
Strikes Again…
Anne Hayes, MD
...forever seeking the
unsuspecting emer-
gency medicine in-
tern. A previously
healthy teenage boy
presented via EMS
with complaints of
weakness,
senso-
ry changes and increasing difficulty of
breathing. Family reported the patient
went outside to mow the grass approx-
imately 10 hours prior to presentation.
After two passes in the yard with a push
mower, the patient had sudden onset oc-
cipital headache, fatigue, parasthesias de-
scribed as tingling in both lower extrem-
ities, and generalized weakness. Patient
reported these symptoms to parents and
laid down to rest. After an hour-long nap,
patient was encouraged to take a shower to
see if symptoms improved. During show-
er, patient became weaker, had one epi-
sode of vomiting and was no longer able to
stand on legs. The patient’s father reports
patient was able to make small movements
but unable to ambulate or push against re-
sistance. Emergency medical services were
contacted at this point, however, after as-
sessment, the symptoms were deemed
related to anxiety and patient was not
transported. Over the course of the day,
the patient’s weakness progressed to the
complete inability to move legs, followed
by inability to move arms, with continued
paresthesias in all extremities. After pa-
tient demonstrated worsening respiratory
distress, EMS was called again. Parents de-
nied history of asthma, prior wheeze, fe-
vers, recent illness or trauma, recent travel
or drug abuse. Family reports patient went
camping one week prior but denies tick
exposure.
On exam, the patient had significant re-
spiratory distress with poor air movement
and was only able to answer questions with
one word responses secondary to respira-
tory distress. Neurological exam revealed
0/5 strength in all extremities, areflexic bi-
ceps and brachioradialis reflexes, areflexic
patellar and Achilles reflexes, and down-
ward going Babinski bilaterally. Sensation
to light touch was intact but diminished in
all extremities. There were no rashes or le-
sions on skin exam.
Initial differential included but was not
limited to:
» » Organophosphate toxicity - although
patient self-decontaminated earlier in
the afternoon and did not have diar-
rhea, salivation, or lacrimation
» » Guillain Barre - although acute time
course without report of recent URI
or GI syndromes
» » Tick paralysis - although no known
exposure or lesions identified on skin
or scalp
» » Transverse Myletitis - although no
personal history of recent illness, no
family history of multiple sclerosis or
other autoimmune disease
» » Spinal Cord Infarct - although patient
and family deny trauma, recent sur-
gery, or history of coagulation disor-
der
» »
Conversion Disorder - although no
anxiety or other psychiatric history
As concern for bronchospasm, the pa-
tient was given IM epinephrine and start-
ed on a ,hour long albuterol while history
was being obtained. Bedside ultrasound
demonstrated grossly normal myocardi-
al contractility without effusion, normal
lung sliding, and a collapsible IVC. Chest
x-ray was unrevealing. After lack of im-
provement with initial intervention, sec-
ond dose of epinephrine and fluid bolus
begun. Intial VBG demonstrated hyper-
capnea and patient was started on BiPAP.
Within minutes, patient showed improve-
ment in respiratory status and appeared
more comfortable. Initial CMP, CBC,
CRP and ESR were unrevealing. Lumbar
puncture was performed after head CT re-
vealed only an arachnoid cyst. CSF studies
demonstrated mildly elevated segs, mildly
elevated glucose, negative gram stain and
normal protein. Foley catheter was placed
after patient complained of bladder full-
ness (confirmed by bladder scan) with
inability to void. Neurology and neurosur-
gery were consulted from the emergency
department, who requested urgent MRI
on admission. Patient was admitted to
PICU with ED diagnoses of acute flaccid
paralysis and acute neuromuscular respi-
ratory failure. After admission, MRI was
(continued on page 28)
SEPTEMBER 2017
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