A 56-year-old woman is brought to the emergency department due to several days of progressive dyspnea, productive cough, and fever. Today, her son found her very short of breath and obtunded. The patient has a history of hypertension, type 2 diabetes mellitus, and long-standing rheumatoid arthritis. Examination reveals bilateral pneumonia and severe respiratory distress. The patient is lethargic without focal neurologic deficits. Urgent endotracheal intubation is performed for mechanical ventilation, and the patient is started on broad-spectrum antibiotics. Repeat examination 2 hours later shows that she has developed areflexic, flaccid paralysis of all extremities. Which of the following is the most likely cause of the neurologic deficits in this patient?

Question

A 56-year-old woman is brought to the emergency department due to several days of progressive dyspnea, productive cough, and fever.  Today, her son found her very short of breath and obtunded.  The patient has a history of hypertension, type 2 diabetes mellitus, and long-standing rheumatoid arthritis.  Examination reveals bilateral pneumonia and severe respiratory distress.  The patient is lethargic without focal neurologic deficits.  Urgent endotracheal intubation is performed for mechanical ventilation, and the patient is started on broad-spectrum antibiotics.  Repeat examination 2 hours later shows that she has developed areflexic, flaccid paralysis of all extremities.  Which of the following is the most likely cause of the neurologic deficits in this patient?

Quizplus · Accepted Answer

This patient with rheumatoid arthritis underwent urgent endotracheal intubation due to severe pneumonia and subsequently developed sudden-onset quadriparesis. Long-standing rheumatoid arthritis frequently involves the cervical spine and causes joint destruction with vertebral malalignment (subluxation). The atlantoaxial joint is most often involved as the atlas (C1) has a high degree of mobility relative to the axis (C2 odontoid and body). Chronic symptoms of cervical subluxation include neck pain, stiffness, and neurologic findings (eg, sensory loss, muscle weakness). Endotracheal intubation can acutely worsen the subluxation and cause compression of the spinal cord and/or vertebral arteries. Acute spinal cord injury results in flaccid paralysis with decreased or absent reflexes below the level of the compression due to spinal shock; the paralysis eventually becomes spastic as spinal shock resolves over the ensuing days to weeks. (Choice A) Cerebral septic emboli are usually due to infective endocarditis of the left-sided heart valves. Patients can develop acute neurologic findings including unilateral paralysis; quadriparesis would be less likely. This patient also has no cardiac murmur or other stigmata (eg, petechiae, splinter hemorrhages) to suggest endocarditis. (Choice B) Diabetic neuropathy presents with a slowly progressive decrease in vibratory sensation, proprioception, and temperature sensation. Early neuropathy can cause decreased ankle reflexes, whereas later disease can cause widespread loss of reflexes with motor weakness. (Choice C) Guillain-Barré syndrome presents with progressively worsening, symmetrical, flaccid muscle weakness with absent or decreased reflexes. The abnormalities typically start in the lower extremities and ascend upward over the course of days to weeks. (Choice D) Malignant hyperthermia is usually due to anesthesia exposure (eg, halothane, succinylcholine), causing increased and sustained muscle contraction with myocyte breakdown. Patients typically develop diffuse muscle rigidity followed by hyperthermia and possible myoglobinuria. Educational objective: Long-standing rheumatoid arthritis can affect the cervical spine, causing vertebral malalignment (subluxation) that can affect the atlantoaxial joint. Extension of the neck during endotracheal intubation can worsen the subluxation, leading to acute compression of the spinal cord and/or vertebral arteries.

A 56-Year-Old Woman Is Brought to the Emergency Department Due