Age: 43.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Fibrin D dimer normal, Gait disturbance, Gamma-glutamyltransferase increased, Gastritis
Clinical narrative: Guillain Barre Syndrome- Several ED Visits between 4/14 and 5/22/21 for GBS symptoms and abdominal pain/gastritis. 5/22 ED Visit -- > Hospital Admission (5/22 to 6/3) back pain with progressive lower extremity weakness and paresthesias x 10 days, consistent with Guillain Barre Syndrome. 43 y.o. female with history of left vestibular schwannoma in 2015 - who presents with back pain as her chief complaint. She has actually been struggling with which has been diagnosis abdominal pain for the past 1 month. She has been seen for headache bilateral lower extremity pain is her first visit mid April. She then was seen for epigastric pain 2 weeks later radiating to her back and she was diagnosed gastritis given H2 blockers. She was seen third time for epigastric pain radiating to her back given medication for muscle spasm and Protonix and checked for H. pylori which ultimately came back and she received a 14-day course of antibiotics which she finished little over 24 hours ago. About 2 and half weeks ago she started to have severe back pain which was worse when she sleeps at night, again was noted to be reported as epigastric pain radiating to her back but it that she says that she primarily has back pain. She has been taking ibuprofen. For the past week she has noted some tingling in her toes and some numbness and she feels very tired in her legs when she tries to walk. Her mid back pain continues. She does have a history of lumbar pain but she says this is entirely different. She has not had any problems eating she does not have any nausea or vomiting no diarrhea. She does not think she has any fevers. CT scan of the abdomen and abdominal ultrasound abdomen have been unrevealing for an etiology of her pain. Hospital Problems:  # New diagnosis of GBS # Tingling/numbness of BLE, bilateral hands # Acute midline thoracic back pain Acute on chronic low back pain with bilateral weakness, diminished sensation, diminished-absent reflexes. Concerning for GBS or AIDP. Blood cultures x2 negative. Neurology consulted and work diagnosis is some type of GBS/demyelinating disease. Patient improved with IVIG and physical therapy and was ultimately discharged home with PT/OT follow-up as outpatient. Also will have neurology follow-up in 3 months. Imaging as noted below. Return precautions extensively discussed with patient. CT T spine without fracture; MRI T spine with no cord compression, MRI L spine with bilateral L5 pars defects, minimal anterolisthesis of L5 on S1, bilateral neuroforaminal stenosis without spinal canal stenosis. LP with clear albuminocytological dissociation - no PMNs seen; need to still f/u with Oligoclonal bands; no concerning cytology or cell count; LP also negative for HSV, VZV, EBV, CMV, enterovirus, west nile, syphilis, bacterial growth in CSF fluid. PMR performed EMG/NCS suggesting motor demyelinating polyneuropathy LLE > LUE S/p IVIG x3 doses Continue gabapentin 300mg PO TID; can likely uptitrate as outpatient Continue PT/OT for one more day F/u with neuro in ~3 months; ordered # Elevated liver enzymes: GGT mildly elevated at 71. No worsening abdominal symptoms. US abdomen shows diffusely echogenic liver consistent with hepatic steatosis, and repeat lipase is within normal limits. Iron normal, CRP normal, TSH normal, d-dimer negative, lactate normal, lipase normal on admission. Smooth muscle antibodies negative, liver-kidney WNL, HCV and HBV negative, ESR within normal limits. LFTs appear to be trending down. Hep B core IgG and IgM negative.  # H pylori gastritis: Reports recently history of H. pylori gastritis, completed 2 weeks of antibiotics/treatment, still having some epigastric tenderness/discomfort occasionally but better prior to discharge. - stopped pantoprazole on 6/1; will need to be off Protonix for at least 2 weeks before rechecking H pylori for clearance - counseled patient to make appt with GI once she leaves  # Microscopic hematuria  - repeat UA with resolution of hematuria    # HTN - continue amlodipine 5 mg PO daily and propranolol  # H/o Vestibular Schwannoma For now will not get MRI as due to have FU as outpatient Advised symptomatic tx and expect symptom resolution over days  F/u Neurology Visit 8/24/21 Past and Interval history:   Paresthesias: Present on toes and fingers/palms, has improved slightly since onset but is still noticeable by patient. Pain: no neuropathic pain, some aching and TTP on lower calf (soleus region), some from mid back that wraps around abdomen (~T8), not as severe as in 5/2021 that prevented her from sleeping.   Weakness: reports dramatic improvement, is able to walk on her own and go up stairs, with moderate exertion has some pain and feels the weakness, just finished PT but is continuing to practice what she was taught at home. \ Review of Systems: Constitutional--Negative for fevers, chills, fatigue Cardiovascular--Negative for orthopnea, PND, and lower extremity edema  Pulmonary--Negative for intermittent dyspnea on exertion, negative for cough or hemoptysis  Objective: Last in person exam 5/30/2021: Neck flexion/extension 5/5 Able to count to 20 in a single breath Muscle Right, Left: Shoulder abduction 5, 5; Elbow flexion 5, 5; Elbow extension 5, 5; Wrist extension 4+, 4+; Finger flexion 4+, 4+; Finger extension 4, 4; Hip flexion 4-, 4-; Knee extension- 4+, 4+; Knee flexion 4+, 4+; Ankle dorsiflexion 4+, 4+; Ankle plantarflexion 5, 5  Sensory:  Decreased vibratory sensation to all distal extremities. Reflexes:  R brachioradialis absent, L brachioradialis 1+. Biceps, Triceps and Knee jerks absent bilaterally with Ankle jerks absent bilaterally. Babinski sign absent.  BP 112/68 (Site: Left Arm, Position: Sitting, Cuff Size: Normal)  | Pulse 67  | Temp 36.5 °C (97.7 °F) (Temporal)  | Ht 1.46 m  | Wt 61.1 kg  | BMI 28.64 kg/m²  General appearance: Normal body habitus. Neurologic exam today:  Mental status:  Oriented to person, place and time. No aphasia.    Cranial nerves:  II: Pupils equal and round  III,IV,VI: extraocular muscles intact  VII: facial muscle function normal bilaterally VIII: hearing intact to conversation  IX: soft palate elevation normal bilaterally XI: trapezius strength normal bilaterally XII: tongue strength normal   Coordination: accurate finger to nose maneuver.   Musculoskeletal: Bulk: normal bulk throughout, Tone: normal tone throughout  Muscle, Right, Left: Deltoid 5, 5; Biceps 5, 5; Triceps 5, 5; Wrist extensors 5, 5; Finger flexors 5, 5; Finger extensors 5, 5; Iliopsoas 5-, 5-; Quadriceps 5-, 5; Hamstrings5, 5-; Anterior tibialis 5, 5; Gastrocnemius 5, 5 Gait: Normal gait. Sensation: intact to light touch over 4 limbs Reflexes: R Biceps 1+, Brachioradialis absent, Knee jerks absent, ankle jerks absent bilaterally. Mute to down going toes Assessment and Plan: Patient is a 43 y.o. female w/ L vestibular schwannoma (2015) presented to ED on 5/22 for back pain with progressive lower extremity weakness and paresthesias x 10 days.  Exam with symmetrical bilateral upper and lower extremity weakness, distal>proximal in the uppers and proximal>distal in the lowers with absent reflexes and diminished vibratory sensation concerning for polyradiculopathy. MRI T- and L-spine were normal.  LP with elevated protein and albuminocytological dissociation. EMG/NCS with evidence of demyelination. History, exam, and workup all consistent with AIDP (Guillain Barre Syndrome) and was treated with IVIG (5/27-5/29). AIDP is a monophasic illness, and patient indeed has had improvement in her symptoms (most prominently strength and neuropathic pain), with residual paresthesias in hands and toes that is not too bothersome. She has not had any new or worsening symptoms to suggest CIDP or an alternative diagnosis. As of 1/19/22 patient reports that she is improving and able to ambulate well. Followed by Neuro.