Patient Presentation

A 35 year old female presented to a local ER with a few days of nausea and vomiting as well as general lethargy.  Patient was given IV fluids and sent home with diagnosis of a GI bug.  A few days later the patient woke up with tingling and weakness of lower extremities and called 911.  She was admitted to the hospital on a general medicine floor for a neurology work up.  Patient continued to have weakness progressing up to her torso and upper extremities and was placed on oxygen when she began to have difficulty breathing. The patient was then transferred to the ICU and was intubated due to paralysis ascending through her body.  After intubation, she was unable to move any extremities other than a slight twitch of a muscle in one arm and one leg and could nod her head yes or no.  Patient remained on the ventilator with full vent support and required a continuous fentanyl drip and Ativan drip for pain and ventilator comfort. 

Differential Diagnosis

When the patient was initially admitted to the medicine floor many ideas were discussed regarding her diagnosis.  Multiple sclerosis, ALS, severe flu-like illness or Guillain-Barre associated with her recent GI illness could all be possible causes for her paralysis.

Diagnosis

It was determined through symptom analysis and a spinal tap that showed increased protein, that the patient was suffering from Guillain-Barre, an autoimmune disorder that attacks the peripheral nervous system following an acute illness.  If treatment was begun immediately the patient should have a positive outcome.

Treatment

The patient began a 5 day course of intravenous immune globulin which should block the antibodies that were damaging the patient’s nervous system.  There was no significant improvement following this course and the patient had a tracheostomy (trach) performed for long term ventilator support.  The patient was able to be weaned from continuous drips to as needed pain medications and was weaned from the ventilator to a trach collar (no ventilator support, just supplemental oxygen).  Also, daily visits from physical and occupational therapy were scheduled to continue to work on regaining strength and muscle mass.

Outcome

The patient was able to be transferred to a regular floor on trach collar and was then transferred to an acute rehabilitation center to work on strength building and work towards decannulation (trach removal).  Most people can completely recover from this illness, but the faster it is recognized and treated, the faster the patient can recover completely.

Case created by Erica Kunkel, 2011.