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23. Guillain–Barré Syndrome: “I May Be Weird, but I Still Can’t Walk!”
Keywords
Guillain–Barré SyndromeAreflexiaAscending weaknessAutonomic dysfunctionCSF proteinLEARNing Rounds
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Case
Tingling and Difficulty Walking
Pertinent History
This patient is a 26-year-old male who presents with progressive leg pain, numbness, and weakness. Starting a little over a week ago, the patient began having numbness and tingling in his left leg. This turned into painful tingling, which then progressed to involve the left fingertips. It spread to include his right leg and now right fingertips as well. It is painful but also feels very numb. He previously was active and states it took him 15 minutes to walk just from a store to the church next door where he sleeps at a homeless shelter. He reports getting a flu shot about 2 weeks ago and shortly after began developing coryza, cough, sore throat, and very foul-smelling diarrhea. He also endorses a couple spells of blurry vision in the past couple weeks that resolved on their own. He denies any fevers. He presented to another Columbus, Ohio, hospital yesterday and had a chest X-ray and head CT done, which he was told were negative and that there may be a psychogenic component to his symptoms. He felt he was being kicked out because he was homeless and had no insurance. He takes no medications except ibuprofen and acetaminophen recently to try to help the pain, which had no effect. He has a history of heroin use.
Notes from Outside Hospital
Nursing Note
“The patient presents with numbness and tingling to the left side starting a few weeks ago. He states that yesterday it went into his right arm and fingertips. It feels like my body is asleep. He also complains of a stabbing left-sided chest pain that came on suddenly 2 days ago. He cannot relate specific activity to pain. He has associated shortness of breath with chest pain. Patient has pain behind his right calf. No redness or swelling. Palpable pulses noted. Patient ambulated with a limp complaining of numbness in his legs. He also states he gets muscle spasms and sometimes feels like he’s going to fall over. He has no respiratory distress noted. He answers questions appropriately he has no facial droop or slurred speech. He admits to a history of heroin use but he has been clean for a long time.”
Clinician Note
“This is a 26-year-old male with a history of heavy polysubstance drug abuse including meth, crack, heroin, alcohol who presents with body numbness. It started in his left leg like and felt it was going to sleep. The feeling has now progressed to his whole body on both sides. The patient also states that yesterday he had terrible chest pain that went on all day and brought him to his knees but today he hasn’t had any. He has never had this before and has had no headaches or vision change. Physical exam findings showed the following: Alert and oriented to person place and time. Cranial nerves II through XII are intact. No motor deficits. No sensory deficits. No extremity tenderness. No edema. Mood and affect are normal. Remainder of exam is unremarkable.”
Pertinent Physical Exam
Except as noted below, the findings of the complete physical exam are within normal limits.
Neurologic Exam:
He displays abnormal reflexes (no reflexes noted bilaterally in the lower extremities, even with distraction.
He displays no atrophy.
A sensory deficit is present as he reports decreased sensation to light touch in the left lower extremity up to hip; right lower extremity up to knee; fingertips feel numb bilaterally to light touch).
No cranial nerve deficits, with II–XII intact.
He exhibits abnormal muscle tone (strength 3/5 bilaterally in the hip flexors, 3/5 bilaterally biceps, triceps). I question this effort because during interview, gross strength appeared 4/5 if not normal.
Gait (knees buckling, shuffling, nearly falling multiple times).
Romberg positive (abnormal).
Lungs:
Clear bilaterally to auscultation.
PMH
Hypertension and diet-controlled type 2 diabetes mellitus.
SH
Smokes tobacco. History of heroin abuse, but clean for the last 4 years.
FH
No pertinent history.
Pertinent Test Results
Lumbar puncture results | |||
|---|---|---|---|
Test | Result | Units | Normal values |
Glucose | 66 | mg/dL | 40–80 mg/dL or < 40% of simultaneously measured plasma level if that plasma level is abnormal |
Protein | 140 | mg/dL | 15–60 mg/dL |
WBCs | 1 | Leukocyte/mcL | 0–5 leukocytes/mcL |
RBCs | 0 | RBC/mcL | 0–10 erythrocytes/mcL |
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