Age: 72.0
Sex: M
Vaccine: FLU3
Symptoms: Withdrawal syndrome
Clinical narrative: Guillain-Barre Syndrome Narrative:  71 year old male with PMH diabetes mellitus type 2 complicated by peripheral neuropathy and cervical and lumbar stenosis, who presented for AIDP/Guillain barre. Patient was in his usual state of health prior to admission. He had an influenza vaccination late October 2020. About three days later he developed numbness and weakness of the bilateral feet and legs. November 3rd he noticed that this began worsening and raising up more proximally up his legs. he also had bilateral hand weakness and numbness which was worsening as well. He presented to a community hospital 11/5 2020 when he also developed bilateral hand numbness and weakness that has been worsening. He was admitted for AIDP . On 11/8/2020 patient required intubation for acute hypoxic respiratory failure due to aspiration and inability to protect airway. He had piperacillin/tazobactam for aspiration pneumonia completed on 11/25/2020, and then was transitioned to amoxicillin/clav. Hospital course was complicated by AKI secondary to contrast induced nephropathy, which peaked to 4.1 before decreasing back to baseline. He received a total of 5 days of IVIG and also suffered from critical illness myopathy. Also has been treated for dysphagia and was on a honey thick liquids and pureed diet. T2DM managed with Detemir 15 units SC BID. Seen by psychiatry on 11/19/2020 for suicidal ideation and cleared at that time (he was started on sertraline 50 mg PO daily). During his acute inpatient rehabilitation stay he initially suffered from delirium with 1 fall while on the unit. He improved drastically after adjustments to his gabapentin. There was suspicion that withdrawal was contributing to his delirium. QTC noted to be prolonged therefore his quetiapine was stopped. Transitioned back to oral antihyperglycemics early in his stay. Initially he was unable to stand secondary to his AIDP and critical illness myopathy. This has improved with therapy. Patient was also initially constipated, but then began having multiple loose stools after being started on an aggressive bowel regimen. He was tested for C diff, which returned negative. Bowel regimen has been titrated down to senna PO QHS. He initially suffered from areflexic bladder with elevated PVRS and no sensation to void. He was trained on intermittent catheterization and sterile cath technique. He eventually developed sensation of needing to void and began having continent voids. Patient had complaints of frequent urination from 4-8 pm. PVR bladder scan followed by a straight cath PVR were obtained, and returned low. It was hypothesized that due to fluid mobilization at the end of the day when patient elevates his BLE triggered his need for frequent urination. He was supplied with a urinal to use in the evenings to minimize the risk of falling. It was discussed that patient may benefit from a urodynamic study in 6 months from discharge. On 12/17/2020 he had acute onset of chills, feeling of recurrent weakness, and malaise. URine found to have bacteria. This was the second UTI he has had since onset of AIDP. CT ordered for R/O Bladder stone, which returned without kidney stones nor bladder stones. However an incidental hyperechoic mass on the kidney was seen bilaterally, with recommendations for MRI renal protocol. Initially patient was placed on trimethoprim/sulfamethoxazole, but due to urine culture resulting with E. coli, he was transitioned to cephalexin (finished a 14 day course) and started on methanamine for prophylaxis. Patient was interested in work up of his BUE tremors while he continued to progress in therapy. He was evaluated by neurologist. Labwork work up was unremarkable and symptoms deemed likely secondary to benign familial tremors. Since patient's quality of life was unaffected and he did not have social embarrassment from his tremors, he declined pursuing medication treatment. Plans are for him to follow up with provider in 6 months from discharge. Patient continued to do well throughout his stay. After being seen and examined by attending physician on 1/22/2021, he was deemed stable for discharge home.