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.