Clinical Reasoning: A middle-aged woman with progressive symmetric weakness and a CSF pleocytosis

Abstract

A 54-year-old Ecuadorian American woman presented with 4 days of progressive bilateral extremity weakness, which began in the upper extremities but quickly spread to the lower extremities. The patient also reported reduced gait stability, bilateral distal paresthesias, and patchy decreased sensation with pain over her lower abdomen and pelvis. At presentation, she denied symptoms of dysautonomia or bulbar dysfunction. Past medical history included longstanding rheumatoid arthritis treated with chronic methylprednisolone, hypertension, left sciatic radiculopathy, scoliosis, uterine prolapse, and thyroid disease.On examination, the patient's vitals were stable. Mental status and cranial nerves were normal. Motor strength was decreased symmetrically in the upper and lower extremities (4/5) with areflexia and absent plantar reflexes. The patient had decreased pinprick sensation over the T6 -T8 dermatomes and diminished vibratory sense distally. Joint position sense was preserved bilaterally. The patient demonstrated a paraparetic slow gait with assistance.

En tenåring med smerter, dobbeltsyn og ustø gange

“…5 % av pasientene med Guillain-Barrés syndrom (6, 8). Intravenøs immun-globulin og plasmaferese er vist å redusere varighet og alvorlighetsgrad av sykdommen (5,6,9).…”

“…80-90 % av voksne pasienter med syndromet har normalt celletall i spinalvaesken en uke etter symptomdebut (6). Pleocytose > 50 celler er så uvanlig at andre aktuelle diagnoser må vurderes, slik som nevroborreliose, hiv, neoplasi, toksisk nevropati, europeisk skogflåttencefalitt og herpesvirus 1 og 2 (6,9,11). I to prospektive studier av henholdsvis 42 og 52 barn med Guillain-Barrés syndrom fant man fra 0-60 celler/l i spinalvaesken, der henholdsvis 59,5 % og 50 % av barna hadde < 5 celler og gjennomsnittet var henholdsvis 6 og 18 celler (12,13).…”