A 24-year-old man is brought to the emergency department by his girlfriend due to progressive weakness. They have been on a cross-country road trip for the past month. While traveling through the midwestern United States 2 weeks ago, the patient developed diarrhea, nausea, and vomiting. He rested, drank fluids, and improved spontaneously after 2-3 days. However, the patient had persistent fatigue, and 4 days ago they had to stop traveling as his legs became too weak to press down the brake pedal. He is now unable to get out of bed. The patient has also had tingling of the hands and feet as well as shortness of breath. He has had no fever, chills, abdominal pain, or recurrent diarrhea. The patient has no prior medical problems and takes no medications. He does not use tobacco, alcohol, or illicit drugs. Temperature is 37.7 C (99.8 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 20/min. Pulse oximetry shows 98% on ambient air. The patient is awake, alert, and speaking in full sentences but develops a weak cough after taking a sip of water. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender. Neurologic examination shows symmetric bilateral lower extremity weakness. Deep tendon reflexes are absent at the knees and ankles, and 1+ in the biceps and triceps. Cranial nerve examination and sensation are normal, and he has no neck rigidity. There is no skin rash or lymphadenopathy. Which of the following is the best treatment modality for this patient?

Question

A 24-year-old man is brought to the emergency department by his girlfriend due to progressive weakness.  They have been on a cross-country road trip for the past month.  While traveling through the midwestern United States 2 weeks ago, the patient developed diarrhea, nausea, and vomiting.  He rested, drank fluids, and improved spontaneously after 2-3 days.  However, the patient had persistent fatigue, and 4 days ago they had to stop traveling as his legs became too weak to press down the brake pedal.  He is now unable to get out of bed.  The patient has also had tingling of the hands and feet as well as shortness of breath.  He has had no fever, chills, abdominal pain, or recurrent diarrhea.  The patient has no prior medical problems and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.7 C (99.8 F), blood pressure is 120/70 mm Hg, pulse is 90/min, and respirations are 20/min.  Pulse oximetry shows 98% on ambient air.  The patient is awake, alert, and speaking in full sentences but develops a weak cough after taking a sip of water.  The lungs are clear to auscultation and heart sounds are normal.  The abdomen is soft and nontender.  Neurologic examination shows symmetric bilateral lower extremity weakness.  Deep tendon reflexes are absent at the knees and ankles, and 1+ in the biceps and triceps.  Cranial nerve examination and sensation are normal, and he has no neck rigidity.  There is no skin rash or lymphadenopathy. Which of the following is the best treatment modality for this patient?

Quizplus · Accepted Answer

Explanation: Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy due to cross-reacting antibodies against peripheral nerve components. Disease-modifying treatment with plasma exchange or intravenous immunoglobulin (IVIG) speeds recovery and reduces the need for mechanical ventilation. Patients with GBS should receive plasma exchange or IVIG if: Nonambulatory Within 4 weeks of symptom onset Those who are ambulatory and recovering generally do not require treatment. (Choice A) Botulism is typically treated with equine serum antitoxin and antibiotics. Patients with botulism usually have symmetric descending weakness (starting in the cranial nerves) with no sensory deficits (except blurred vision). This patient with weakness that began in his legs and paresthesias is much more likely to have GBS. (Choice B) Transverse myelitis is typically treated with high-dose glucocorticoids. Manifestations typically include motor weakness, paresthesias, and autonomic dysfunction (eg, bowel/bladder dysfunction). Most patients have a sensory level deficit. This patient with recent gastrointestinal illness who developed symmetric motor weakness, diminished reflexes in the upper and lower extremities, and potential respiratory compromise (weak cough, tachypnea) is more likely to have GBS. (Choice C) Amyotrophic lateral sclerosis is a degenerative motor neuron disease that usually manifests with asymmetric limb weakness of the hand or foot (eg, foot drop) and can be treated with riluzole and supportive care. Most cases arise in those of advanced age (>70). This young patient with symmetric, rapidly progressive weakness after a gastrointestinal illness is more likely to have GBS. (Choice D) A spinal epidural abscess (SEA) is often managed with surgical decompression and antibiotics. SEA usually manifests with slowly progressive back pain, fever, and neurologic deficits (eg, paresthesia, motor weakness, bladder/bowel dysfunction). This patient is afebrile with no back pain, making SEA unlikely. Educational objective: Guillain-Barré syndrome is treated with plasma exchange or intravenous immunoglobulin to speed recovery and reduce risk of respiratory failure. Patients who are nonambulatory should receive treatment if symptoms have been present <4 weeks.

A 24-Year-Old Man Is Brought to the Emergency Department by His