Sun28November0440PM 7

You are asked to review a 24-year-old man who was admitted to hospital with an ascending muscle weakness which began in his toes but now affects all his limbs.

His breathing has become shallow. He has preserved sensation but his reflexes are absent. Currently his cranial nerve examination is normal and he is fully orientated.

Apart from a diarrhoeal illness three weeks ago he has no past medical history and he takes no medications.

What is the most likely diagnosis?

(Please select 1 option)

Guillain-Barré syndrome Correct

Botulism

Diphtheritic neuropathy

Miller Fisher syndrome

Tetanus

Explanation

This is the classic presentation of Guillain-Barré syndrome.

Guillain-Barré syndrome is an immunological phenomenon post-infection whereby the body attacks the peripheral nervous system causing a demyelinating polyneuropathy. This usually presents several weeks after illness and there is a strong association with a diarrhoeal illnesses caused by Campylobacter jejuni. The patient will usually present with an ascending paralysis which in extremis can result in respiratory paralysis and death from respiratory failure.

Treatment depends on recognition, respiratory monitoring and sometimes respiratory support. There is limited evidence for intravenous immunoglobulin.

Miller Fisher syndrome is a variant of Guillain-Barré but presents with cranial nerve palsies.

Botulism toxicity can result in respiratory failure and paralysis but this classically occurs in a descending fashion.

Diphtheritic neuropathy causes palatal weakness and papillary paralysis.

Tetanus is rare in immunised people however farmers are at high risk due to the environment they work in, that is, skin lacerations and being exposed to manure. Tetanus would present with signs of infection and spasms not weakness.

Reference:

Kumar P, Clark M. Kumar and Clark Clinical Medicine. 6th ed. London: Saunders; 2005.

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