A 27-year-old man is brought to the emergency department with difficulty walking. He noticed leg weakness several days ago, and now he is barely able to walk. He also complains of foot tingling. Two weeks ago, he had an upper respiratory tract infection that resolved on its own. Review of systems is negative for fever, headache, neck or back pain, or other symptoms. Vital signs show tachycardia and orthostatic hypotension. Physical examination shows bilateral lower-extremity muscle weakness and absent knee and ankle reflexes. Sensation is intact. Cerebrospinal fluid analysis of this patient would most likely show which of the following results?

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11ec25c8_d482_edd4_bc81_df88041fd512_MD0003_00 Guillain-Barré syndrome is an acute or subacute ascending polyradiculoneuropathy that is often preceded by an upper respiratory tract infection or diarrheal illness (eg, Campylobacter jejuni). It typically presents as bilateral leg weakness that ascends to the arms, respiratory muscles, and face to generalized flaccid paralysis. Distal paresthesias are common, but other sensory symptoms are uncommon or mild. Reflexes are diminished or absent. Autonomic disturbances are common and include tachycardia, bradycardia, hypertension, orthostatic hypotension, and urinary retention. Cerebral spinal fluid (CSF) analysis shows a high protein concentration with normal white blood cell (WBC) counts (albuminocytologic dissociation). The CSF protein level may be elevated due to increased permeability of the blood-nerve-barrier. CSF red blood cell (RBC) and glucose levels should be normal. Gold standard treatment includes intravenous immunoglobulin or plasmapheresis. Patients should be monitored closely due to risk of respiratory failure. Most patients take several months to recover. (Choices A and C) Bacterial, fungal, and tubercular meningitis generally presents with elevated protein, low glucose, and elevated WBC counts. The RBC count should be normal, although the presence of RBCs can reflect accidental trauma to a capillary or vein during lumbar puncture. (Choices B and D) Viral meningitis typically has elevated WBC count, and normal RBC and glucose counts. Protein level can be normal to slightly elevated. The exception is herpes meningoencephalitis, which can have high RBC and protein levels reflecting temporal lobe hemorrhage. (Choice F) Normal CSF has <5 WBCs or RBCs. The blood-CSF barrier minimizes protein entry and the protein count is usually <40 mg/dL. The normal CSF glucose level is 40-70 mg/dL, or approximately 2/3 of serum glucose. Educational objective: Guillain-Barré syndrome is an acute or subacute ascending flaccid paralysis. Cerebrospinal fluid analysis shows an elevated protein level with normal cell count (albuminocytologic dissociation). References: An appraisal of blood-cerebrospinal fluid barrier dysfunction during the course of Guillain Barré syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/19587469) Guillain-Barre syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/22081202)

A 27-Year-Old Man Is Brought to the Emergency Department with Difficulty