Age: 31.0
Sex: M
Vaccine: FLUX, MMR
Symptoms: Influenza virus test negative, Mononucleosis heterophile test negative, Myalgia, Neurological examination normal, Paraesthesia
Clinical narrative: Pt received: MMR, Flu vaccine (unknown type) and PPD placed at same time at unknown facility about 3wks prior. He then presented to overseas 23April2018: 31 YO male presents with 3 day history of symmetric bilateral numbness starting in the toes with progression to the waist. He describes the numbness as tingling in whole distribution of his legs through waist anterior and posterior. He denies pain or frank weakness in the LE; however, states that it is difficult to walk due to the numbness. He also reports headache onset 3 days prior. The headache is constant, all over and is not associated with photo- and phonophobia, nausea or vomiting. He has had headaches like this in the past; however, they usually improve with acetaminophen. He bought OTC acetaminophen cold and flu due to the symptoms. However, this morning, he started to have low back pain, facial pain, and difficulty swallowing prompting him to report to hospital. He denies trauma and has no prior history of similar back or facial pain. He noted the dysphagia this morning described as a lump in his throat. This prompted him to mash a banana prior to eating it. Due to anorexia, this is the only food he has eaten. In further discussion with the patient, he did receive influenza, MMR vaccines and a PPD placement within the past 3 weeks in preparation for this job/travel. He denies incontinence or retention of bladder/bowel. No sick contacts. No diarrhea, blood in stool, or abdominal pain. He denies fevers, emesis and nausea, odynophagia. He denies acute life stressors. Of note, the patient reports similar symptoms around 2010-2011. At that time, he was in another country. He had similar paresthesias but only progressed to the calves. He did not require admittance to hospital or treatment. He was observed for 3 months continuing to work daily. No family history of neurological disease. At the time of presentation, he did not have respiratory compromise. Given the recent immunization, ascending parasthesias, URI symptoms, and present but mute reflexes, the primary concern was for Guillain-Barre Syndrome (GBS). Other diagnoses were considered and evaluated to the best of our medical unit's capabilities--- MS, botulism, CNS source-mass lesion, radiculopathy, electrolyte abnormality, were unlikely based on serially exams, rads, and labs. Monitoring of his respiratory function. Tele-Neurology was consulted and was in agreement with the medical team that IVIG should be started given the level of numbness (waist) at presentation. He was thus started on IVIG at 400mg/kg/day x 5 days. He tolerated the first infusion well on 23 April 2018 at 1730, second infusion on 24 April 2018 at 17:30. The patient was monitored with serial neurological exams as well as NIF and peak flow that remained stable. His NIFS at time of discharge were -45cmH20, his peak flow was Peak Flow 460-490. Given the need for more diagnostic work-up- MRI, EMG and LP With protein concentration as well as the potential for progressive disease resulting in respiratory compromised, the patient was arranged a medical paramedic transport team to another country by his contracting company. Exam on day of discharge: Vitals: T 98.0 HR 95 BP 152/98 RR18 95% RA. HEENT: MMM, no scleral icterus, PERL, EOMI, No nystagmus; funduscopic exam without acute abnormalities. CV: RRR, no r/m/g. Lungs: CTA B/L; good air movement bilaterally. Abd: NT, ND normal active bowel sounds. GU: Rectal tone intact; prostate normal in size; no blood on glove. Neuro: Alert and oriented to person place and time. CN2-12 intact. Strength: 5/5 in bicep, delts, interossi, quad, dorsi- and plantar flexion. Reflexes: 1+ reflexes at brachioradialis and biceps, Mute (0) at patella, Achilles (unchanged from admission). Sensation: Intact to light touch but symmetrically decreased in lower extremities in stocking glove pattern all the way to bilateral symphysis pubis. Cerebellar: Intact to H2S, Intact to RAM. Romberg: Normal; able to maintain positioning; no pronator drift. Gait: Able to walk unassisted several steps. MKS: 2+ pulses bilaterally; pain to palpation in left lateral paraspinal muscles.