A 30-year-old previously healthy man comes to the emergency department due to back pain and difficulty walking. His symptoms began 4 days ago with lower back pain, which he attributed to moving furniture around his apartment. The patient also experienced a tingling sensation in his feet and hands and by the next day had difficulty walking. His weakness has gradually progressed and he has also experienced frequent episodes of palpitations, excessive sweating, and dyspnea. The patient has not travelled recently and reports no recent respiratory or gastrointestinal illness or vaccinations. He takes no medications, drinks alcohol occasionally, and does not use tobacco or illicit drugs. He has had 2 sexual partners over the past year and uses condoms inconsistently.
On examination, the patient is alert and cooperative. Bilateral pupils react sluggishly to light and accommodation. His speech is slightly dysarthric with mild weakness of the buccinators. Bilateral upper extremity motor strength is 4/5 with hyporeflexia, and bilateral lower extremity tone is decreased with 3/5 motor strength and areflexia. Vibration and proprioception sensations are reduced in the feet bilaterally. Coordination and gait testing are limited by weakness. There is no spine tenderness or neck rigidity.
Which of the following would be most helpful in establishing the diagnosis in this patient?

Question

A 30-year-old previously healthy man comes to the emergency department due to back pain and difficulty walking.  His symptoms began 4 days ago with lower back pain, which he attributed to moving furniture around his apartment.  The patient also experienced a tingling sensation in his feet and hands and by the next day had difficulty walking.  His weakness has gradually progressed and he has also experienced frequent episodes of palpitations, excessive sweating, and dyspnea.  The patient has not travelled recently and reports no recent respiratory or gastrointestinal illness or vaccinations.  He takes no medications, drinks alcohol occasionally, and does not use tobacco or illicit drugs.  He has had 2 sexual partners over the past year and uses condoms inconsistently.
On examination, the patient is alert and cooperative.  Bilateral pupils react sluggishly to light and accommodation.  His speech is slightly dysarthric with mild weakness of the buccinators.  Bilateral upper extremity motor strength is 4/5 with hyporeflexia, and bilateral lower extremity tone is decreased with 3/5 motor strength and areflexia.  Vibration and proprioception sensations are reduced in the feet bilaterally.  Coordination and gait testing are limited by weakness.  There is no spine tenderness or neck rigidity.
Which of the following would be most helpful in establishing the diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_9665_bca1_853d_4bf30530152a_MD0002_00 This patient with back pain, paresthesias, symmetric weakness worse in the lower extremities, and hyporeflexia likely has Guillain-Barré syndrome (GBS), or acute inflammatory demyelinating polyneuropathy. Classic GBS presents as a progressive, symmetric ascending weakness or paralysis, often a few days to a week after a respiratory or gastrointestinal infection (especially Campylobacter jejuni). About one-third of patients have no history of antecedent illness. As the weakness ascends (eg, difficulty walking with 3/5 strength in the lower extremities compared with 4/5 strength in the upper extremities in this patient), bulbar symptoms (eg, ophthalmoplegia, facial diplegia, dysarthria, dysphasia) and respiratory compromise can develop. Back pain can be a presenting feature of GBS as the disease targets primarily the proximal nerves and nerve roots in either the cervical or lumbar spine. Although GBS is primarily a motor polyneuropathy, patients can have mild sensory symptoms such as paresthesias and sensory ataxia. GBS patients also are at risk of developing dysautonomia (eg, tachycardia, diaphoresis, sluggish pupils). Examination shows absent reflexes. Lumbar puncture is indicated in all suspected GBS patients to rule out infectious etiologies and document elevated cerebrospinal protein with a normal cerebrospinal fluid white blood cell count (albuminocytologic dissociation). However, lumbar puncture may not be diagnostic in some GBS patients as it may take up to a week after symptom onset to see the abnormal findings. Nerve conduction study and electromyography are also indicated to confirm the diagnosis and estimate prognosis. Treatment is mainly supportive, with plasma exchange or intravenous immunoglobulin. Current evidence does not recommend corticosteroids as they are not beneficial. Most patients recover within several weeks to months. (Choice A) Acetylcholine receptor antibodies are useful for diagnosing myasthenia gravis, which usually presents with fluctuating muscle weakness and muscular fatigue. However, myasthenia gravis usually does not present as a rapidly ascending weakness. (Choices C and D) The topographical pattern of deficits in this patient (bilateral symptoms) would not be consistent with a focal structural lesion in the brain (eg, stroke or tumor). MRI of the cervical spine would be low yield in this patient as it would not explain the abnormal cranial nerve findings. This patient also does not have upper motor neuron signs (eg, brisk reflexes) to suggest myelopathy. (Choice E) Serum rapid plasma reagin test is used to diagnosis syphilis. Tabes dorsalis (a manifestation of neurosyphilis) can cause sensory ataxia, paresthesias, back pain, and abnormal pupillary response (Argyll-Robertson pupil). However, it does not cause ascending weakness, and Argyll-Robertson pupils accommodate but do not react to light. Educational objective: Guillain-Barré syndrome is an ascending weakness that develops approximately a week following a respiratory or gastrointestinal infection and has been strongly associated with Campylobacter jejuni infection. About one-third of patients have no history of antecedent illness. An increased cerebrospinal protein with normal white blood cell count (albuminocytologic dissociation) suggests the diagnosis but may not be present for up to a week after symptom onset. __________ References: Guillain-Barré syndrome: a team approach to diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/8677835) Guillain-Barre syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/22081202)

A 30-Year-Old Previously Healthy Man Comes to the Emergency Department