Age: 24.0
Sex: M
Vaccine: HEPAB, MNQ, TDAP
Symptoms: Alanine aminotransferase normal, Antiacetylcholine receptor antibody positive, Aphasia, Aspartate aminotransferase normal, Asthenia
Clinical narrative: The pt entered boot camp on 8/24/09. He received HepA/b, Tdap and Meningococcal vaccinations on 8/25/09. The pt and URI like symptoms (cough, congestion, sore throat-although pt states it might have been from yelling, no rhinorrhea, no sneezing) since 9/1/09 but he did not go to medical because "everyone in the platoon was sick". The pt was seen in medical on 8/31/09 for a rash to his shins and neck. It was noted that the pt's temp was 99.4. The patient was seen in medical on 9/14/09 for a 3 day history of complaints of dizziness, disorientation, blurry vision, and tingling in his hands and feet and two week history of cough and congestion. No weakness was noted on exam but decreased reflexes were noted to lower extremities bilaterally. The pt was started on BACTRIM for cellulitis (neck) and ZITHROMAX, MUCINEX, ZYRTEC, TYLENOL and CEPACOL for his URI. 9/16/09 the pt was seen in medical for trouble swallowing, speech difficulties, numbness in his feet, numbness in his hands extending to his forearms and generalized fatigue/weakness. The PE noted: reduced strength of the BUE, abnormal gait, abnormal reflexes, abnormal sensory exam, right lid lag and speech difficulties. The pt was refered to a civilian neurologist for evaluation on 9/16/09. The pt mentioned that he had a hx of GBS (symptoms of double vision, numbness and weakness) in 199 after being ill with a cold. The patient had a NCS (see below), He was transferred to hospital and admitted to the ICU for 24 hours. Symptoms at that time were: weakness BUE and BLE, numbness in palms and legs, dysphasia, dyspnea, mild lower back discomfort, lack of energy and mild facial weakness. Physical exam revealed: mildly dysarthric speech with a predominant pharyngeal and labial component; pupils sluggishly responsive to light; left afferent papillary defect; eye movements reduced with up-gaze and right gaze with conjugate gaze; abduction deficit OS on looking left; soft palate does not elevate of either side; mild right ptosis; strength is very mildly diminished in the distal muscle groups in diffuse fashion in arms and legs; absent biceps, triceps, knee jerks and ankle jerks; no Babinski sigh; steppage gait. The pt received IV IG 0.4mg/kg/day for 3 days with improvement of his symptoms. He was transferred to acute rehab on 9/18/09. Medical record notes indicate that the pt had dysarthria, mild dysphagia, left afferent papillary defect with diplopia, and mild generalized weakness. The pt was transferred to VA Rehab on 10/6/09. Evaluation indicates that the pt was able to perform all ADLs independently; his had residual diplopia related to left ophthalmoparesis; his speech was improved. As of 10/14/09 the pt continued with PT, OT, ST and vision therapy. Pt had an eye patch which was alternated between eyes every hour while awake. The pt was evaluated by Ophthalmology on 10/21/09. The note indicates some improvement in the right eye diplopia with the recommendation for continued follow-up at this time and possible surgery if no improvement in 6 months. Neuro consult was pending. Symptoms: Inability to swallow (CN IX, X), Fatigue, Malaise <60 Days, Hypo-reflexia, Dizziness, Cognitive deficiency, Blurred Vision, Paresthesia, Cough, productive, Pain, Pain, Fever, Rash, focal. 10/27/2009 hospital and Rehab records received for 9/16-10/2009 .Patient initially with  c/o's flu-like sx, cough, congestion and sore throat, rash and fever which progressed to sx of weakness, diplopia, rt eyelid droop, dysarthria, dysphasia.  and numbness/tingling in extremities. Neuro consult noted per PE, absent reflexes, decreased strength, abnormal gait. Tx'd with IVGG, extensive Rehab to include PT/OT/ST.  DX : GBS