THE UNSOLVED PERIPHERAL NERVE MYSTERY OF 20M

A 20 year old man presented with the chief complaint of weakness in all 4 limbs. In early November, while settling down for a grand dinner with his family, the patient reported to have had a heartful meal and when he was finished he noticed that he had some difficult in getting up from a seated position on the floor. When we where interviewing him and at this point we asked if this was the first time he ever felt weak and he recollected that he felt weakness in his toes earlier than this event and he reported that his footwear was slipping off from his feet. Reasoning it to his allegedly poor diet, he ignored this symptom, however on the day he couldn't get up from the floor, he realised  his weakness wasn't improving inspite of taking an improved diet and that led him to consult a doctor in Hyderabad. At that point he had some difficulty in walking, getting up from seated positions and a difficulty in playing cricket which led him to abandon the sport. He did not report any difficulty in rolling in bed, getting up from bed in the morning or any weakness in his upper limbs. He reported a vague tingling sensation, restricted to his feet at that point. After seeking consultation with a neurologist, he got some tests done which revealed a 'nerve problem'. He reported that his sensory symptoms vanished with the drug the doctor prescribed. He also reported a mild improvement in his weakness at that point but a complete resolution wasn't attained. With a slightly improved functional ability he was able to get back to his daily activities, however playing cricket remained elusive. He changed his footwear to sandals and he says since then slippage of footwear stopped. On direct questioning he still reported a vague weakness in his toes and feet. 

Over the next few months, the patient started to have progressive weakness of his lower limbs which have now resulted in a significant impairment in walking. He also says that since the lockdown began, he has been having tingling sensation in his feet, which gradually progressed to his knees. With schools and colleges indefinitely suspended and having to stay at home and playing cricket remaining elusive, the patient was distressed. The concerned parents were also worried about the progressive weakness. When asked how he felt while walking, the parents and the patient alike reported that his weakness progressed from March to June to a point where he had buckling of his knees. At this point in May, they felt that a neuro consult was warranted, however the lockdown was in full effect and getting medical care proved cumbersome. In mid June, when the lockdown eased, the patient sought a neuro consult. At this point he reported to us that he couldn't hold his phone, he had difficulty in mixing food with his fingers and holding mug while taking a bath. When asked if he ever had instability of gait, the patient recalls that one night in March, when he woke up in the night to drink water, he felt instability of his stance in the dark. He says that since that moment, his weakness has worsened and even daily activities were now becoming difficult. He also said that the same tingling he felt in his legs, he also felt in his hands, just above the wrists on both sides. He also required assisted living with help needed to get him up from bed, making him stand and helping him along to the bathroom. 

A Neuro consult taken on 23rd June reaffirmed the same thing - He had a 'nerve problem'. Distressed and with no solution in sight, the patient presented to us in this current state. 

He is the youngest of 2 children (both boys) to his parents. He is currently a final year student, pursuing B.com. His past history is significant for allergic sinusitis and rhinitis. He also reported having an abdominal surgery for an intestinal problem. He also got operated for a nasal polyp at age 12. He said that since the last 8 years, he hasn't been having any allergic symptoms

PAST HISTORY:six months back-loss of appetite,generalised weakness,difficulty in getting up from squatting,6 days later difficulty in wearing chappaĺs,4 days later difficulty in walking,2 days later bending on walking next whent to hospital in Hyderabad.medicines were precribed for 3 months.they used for 1.5 months and stopped

June 2020:stooping with short steps .2 dad later there was buckling. 3 days later there was tingling and numbness in bilateral kness,3 days later progressed to proximal limbs-progressive and static.

Tingling of limb since 15vdays upto wrist,bilateral symetrical since 10 days.difficulty in combing of hair after 3 days.

GENERAL EXAMINATION:patient is conscious,coherent,cooperative 

vitals temp:afebrile

Bp:160/90 mm hg decreased on standing

Pr:63bpm

Rr:21 cpm

No pallor,icterus,cyanosis clubbing,lympadenopathy and pedal edema

SYSTEMIC EXAMINATION 

CVS EXAMINQTION:s1 s2 heard,no murmurs

RESPIRATORY SYSTEM:bilateral air entry present

Normal vesicular breath sounds heard

CNS EXAMINATION:highter mental functions

Gcs 15/15

Oriented to time,place,person

Language:

Speech fluency intact,repetation,naming and comprehension intact

Memory:intact

Cranial nerves:intact

No meningeal signs

BULK                  RIGHT           LEFT

 Leg                   28 cm               27cm

Lower leg        17cm               19cm

Midthigh         37cm               37cm

Biceps              24cm              23cm

Forearm          22cm              22cm

TONE       RIGHT             LEFT

        Upperlimb   decreased      decreased 

      Lowerlimb    decreased       decreased 

      Reflexes       right                left

     Triceps         .....                   ......

    Supinator    .......                   ......

    Knee              .....                    .....

     Ankle            .....                    .....

     Plantar       flexion             flexion

POWER                                  RIGHT              LEFT

Flexor hallucis longus       4/5                   4/5

Extensor hallucis longus   3/5                  3/5

Ankle in flexion                   4/5                  4/5

Ankle in dorsiflexion          3/5                   3/5

Hamstrings                          3/5                   3/5

Quadriceps                          3/5                   4/5

Gluteus                                4/5                   4/5

Iliospoas                               3/5                 4/5

Biceps                                    4/5                  4/5

Triceps                                  4/5                 4/5

WRIST:

Extensor                              3/5                  3/5

Flexor                                  3/5                   3/5

Hand grip                            10                    10

Deltoid                                4/5                   3/5

Infraspinatous                  4/5                  4/5

Proprioception, vibration,fine touch-lost in both lower limbs upto knee joint.

No cerebellar signs,no cranial nerve abnormalities 

INVESTIGATIONS:

Cbp

Cue:normal

Pt:15 sec,INR:1.11,APTT:30 sec 

Blood group:b+ve

Hcv -ve

Hiv -ve

Hbsag -ve

RFT:urea:26mg/dl

Creatinine:0.4mg/dl

Uric acid:4.6 mg /dl

Ca:10.1 mg/dl

Na:134meq/l

K:3.9meq/l

Cl:99 meq/l

LFT:total bilirubin:1.03mg/dl

Direct bilirubin:0.30mg/dl

Ast:51 iu/l

Alt:86 iu/l

Alkaline phosphate:154 iu/l

Albumin :3.8 gm/dl

Rbs:117mg/dl

Hemogram:platelets:2.52 lakhs/ccm

Total count:5000cells/ccmm

Hb:13.6gm/dl

Esr:50 mg

Tsh:0.57

Ecg

2D ECHO:EF:64%,RVSP:35MM HG,trival tr+/ar+,no mr,no rwma,no as/ms,no pah/pe,good lv systolic function 

Urine for bence protein-negative,

Spot urine protein-6,creat-58,ratio:0.1

Direct and indirect antiglobulin-negative

TREATMENT GIVEN:

1)IV IG 0.4 gm/kg per day in 200ml Ns/Iv for 5 days

2)inj.optineuron 1 amp in 100ml Ns/Iv/Od

3)tab.telma 40 mg/od

4) monitor bp,pulse and rr

5)physiotherapy of all limbs

6)single breath counting

ADVICE AT DISCHARGE:

1)TAB mvt od

2)tab.telma 40 mg od

3)physiotherapy of all limbs

4)single breath counting.

DIAGNOSIS:

RECURRENT GBS

CHRONIC INFLAMMATORY AXONAL NEUROPATHY 

https://drive.google.com/folderview?id=1M8FCDA9JKT2qUUxHjvjR-MUT98EZmpCi

https://drive.google.com/folderview?id=1NYzlvw35kd1BMZa5rMgarFzsq9zIjnJH