Case Presentation:
A 61-year-old Indian female with a past medical history of diabetes
mellitus and chronic mechanical back pain presented with progressively
worsening lower limb weakness, gait difficulty, and reduced sensation in
the abdomen and lower limbs. and numbness in her trunk and bilateral
lower extremities. She denied urinary or bowel incontinence. There were
no abnormal movements or a reduced level of consciousness. Her symptoms
were preceded by a febrile watery diarrheal illness 7 days before the
onset of these symptoms. However, on presentation, her diarrhea had
already subsided. Family and social history were unremarkable. Her vital
signs were within the normal range. Physical examination showed intact
consciousness, speech, and cranial nerves. Lower limb power was 3/5
proximally and 4/5 distally. Reflexes were 1+ in the upper limb and
areflexia in the lower limb. The sensory exam showed loss of sensation
in all modalities, including light touch, pain, temperature, joint
position, and vibration below the T6 level. Finger to-nose and heel to
shin tests were normal, but gait was unsteady.
The initial workup showed leukocytosis (WBC of 12.000) with a normal
complete metabolic profile. urgent Magnetic resonance images (MRI) of
the whole spine (figure 1) to exclude transverse myelitis or cord
compression were inconclusive apart from mild multilevel degenerative
changes seen in the mid-cervical, mid-dorsal, and lower lumbar regions,
predominantly at the level of C5-C6, C6-C7, T8-T9, L3-L4 and L4-L5. CSF
studies showed protein of 1.57 gm/dl with normal cell counts consistent
with albumin-cytologic dissociation(Table 1). CSF tests for infection
were unremarkable as well, including bacterial and virologic studies.
Nerve conduction studies showed absent F-waves of both perineal and
tibial nerves, otherwise an unremarkable study. Needle examination
revealed positive sharp waves with decreased recruitment in both
iliopsoases, consistent with early neurogenic changes. Denervation was
also seen in the L1-L2 paraspinal muscles.
In view of her clinical presentation of acute flaccid paralysis with
areflexia, unremarkable MRI findings, CSF albumin-cytologic
dissociation, and absent lower extremity F-waves, she was diagnosed with
having possible GBS and she was started on a 5-day course of intravenous
(IV) immunoglobulin with a standard dose of 0.4 gm/kg, which was later
followed by a 5-day course of IV pulse methylprednisolone. At first, her
lower limb weakness worsened to 1/5 and she developed bowel and bladder
dysfunction.
A follow-up MRI of the spine 1 week after the first one did not show any
new changes. Over the next 2 to 4 weeks, the patient started to recover
gradually, with improvement in her sensations first, then full recovery
of motor symptoms with active rehabilitation with the help of an
occupational therapist and physiotherapist. On follow-up four months
later, she remained independent in all activities of daily living.