ditch doctor
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A 24yo female is brought into the ED by her roomate because she is unable to move her legs and is starting to have weakness in her arms as well. She became scared when she had to "work harder" in order to breath. She is working in a North Carolina barbecue restaurant and tells you that she had "food poisoning" about two weeks ago. She describes her paralysis as coming over her in about "4 or 5 days", starting with problems walking and has been moving upwards. It now affects her arms and breathing as well.
Which of the following could have most likely prevented her paralysis:
A. Avoiding raw or undercooked hamburger
B. Avoiding raw or undercooked poultry
C. Use of antibacterial soap for hand washing
D. Use of N,N, diethyl-m-toluamide (DEET)
E. Avoiding close contact with infected persons
F. Only eating properly canned vegitables and fruit
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| achilles
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F ?
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| Geroo
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i go with F too
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| msyamp
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I think its B to avoid campylobacter
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| cyra
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I'd go with B too.She has an ascending paralysis and the prior history of "food poisoning" points to a Dx of GB syndrome.So yeah...avoiding raw/uncooked poultry seems to be it.
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| docofthebigapple
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F is not the answer. Clostridium botulinum causes botulism which can mimic similar symptoms but the difference from this case will be that botulism will cause descending paralysis and not ascending type as seen here.
without googling and going into books, i am unable to pick an answer but i can exclude F for the reasoning i gave above.
A. undercooked hamburger = E coli.
B. poultry could be salmonella or campylobacter
C. hand wasing is for staph aureus.
I think its guillain barre syndrome associated with campylobacter jejuni. Answer is very likely B
I don't know what DEET is. Unable to rule out other choices.
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| achilles
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ah !! a straight forward case and i miss it. yes it should be B. isnt it strange that the closer i am to my exam the more questions i am starting to get wrong. i think i was better off a month back !! i know things and i am not able to still get it right. now this was a straight forward easy question and i have to think of something strange and not the obvious !!!! thanks guys for waking me up. i need it.
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| ditch doctor
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D. Use of N,N, diethyl-m-toluamide (DEET)
This patient is most likely suffering from Tick Paralysis. The two keys to this question that make tick paralysis most likely are the pattern of paralysis (ascending) and the time course (from 2 to 7 days). Also, expect intact neuro sensory exam and a normal CSF.
Tick paralysis (Tick Toxicosis) is a zoonotic disease caused by neurotoxins present in the saliva of the female Dermacenter, Amblyoma and Ixodes spp. It is one of the 8 most common tick borne illness in the US. Treatment is to remove the tick as soon as possible. Afterwards the symptoms will spontaneously resolve over time, usually under 24hrs. Remember to keep in mind the possibility of more than one tick when searching for ticks; a completely thorough search must be made. If the tick is not removed paralysis of the respiratory muscles can ensue. Untreated tick paralysis has a mortality of about 10-15%.
Removal of a tick is best by grabbing the tick as close as possible to skin with tweezers or forceps and gently pulling the tick out. Anecdotal uses of making a wheal with lidocaine with epinephrine under the tick have been reported. This cuts of the blood supply to the tick and they should detach themselves, but this is not officially reccomended.
Prevention is by avoiding tick infested areas and by using an insect repellant with N,N, diethyl-m-toluamide, a commercial insect repellant also known as DEET. DEET is very effective in repelling most insects, however there have been reported some adverse effect with continued use in children.
Most patients will not recall or even notice a tick bite.
A. Eating well cooked hamburger would prevent E. coli and Hemolytic Uremic Syndrome could follow. While you can have neurological symptoms with HUS, this is not the typical presentation of HUS which makes this diagnosis unlikely.
B. Avoiding undercooked chicken would prevent C. jejuni, an infection that has been associated with Guillain Barre Syndrome. Guillain Barre does present with an ascending paralysis and would follow a "food poisoning" incident by 2-4 weeks. However, Guillain Barre *usually* takes longer for the symptoms to manifest. The average peak of symptoms is around 12-13 days and nearly all patients have peaked within a month. This is day 4 or day 5 and the patient above is already affected in most of her body with impending respiratory compromise. She also lives in North Carolina, a tick endemic area. Also, the risk of GBS after C. jejuni is very small, less than 1 case per 1000 C. jejuni infections. So, while answer choice B is a "correct" answer, it's not the *most likely* answer. Clearly, if a very careful search yeilded no tick on the above patient, GBS would be more likely. Also, in GBS you can see parathesias in the hands and feet and other loss of sensory functions. CSF also shows the characteristic albunino-cytologic dissociation, however it remains normal in about 1 out of every 10 GBS patients, so a negative CSF cannot rule out GBS.
C. Frequent hand washing with antibacterial soap would prevent the spread and ingestion of several of the orally ingested microbes, but would not prevent a tick bites. There is controversy as to whether the frequent use of antibacterial soaps is leading to the natural selection of so called "super bugs", which are naturally resistant to different anti-bacterial agents.
E. Only eating properly canned foods would help to prevent Botulism. However, botulism is unlikely here because botulism tends to be a descending paralysis. Also, you would expect other symptoms besides paralysis. From eMedicine: "The typical progression of symptoms (in order of appearance) in a botulinum neurotoxin poisoning can be summarized by the Dozen D's: dry mouth, diplopia, dilated pupils, droopy eyes, droopy face, diminished gag reflex, dysphagia, dysarthria, dysphonia, difficulty" lifting head, descending paralysis, and diaphragmatic paralysis
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| cyra
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wow!This was a tricky(read devilish) one!  So,the key here would be to recognise the shorter time period in which the symptoms manifest for tick fever,no paresthesias...and of course a high index of suspicion.
Great question ditch doctor...thanks for posting!
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| achilles
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turns out that this was not so straight forward a question.gr8 question ditch doctor thanks...pls keep posting more questions.
moral of the story:be suspicious of a man who appears too nice and straight, there might be more to him.
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| ditch doctor
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cyra wrote:wow!This was a tricky(read devilish) one! So,the key here would be to recognise the shorter time period in which the symptoms manifest for tick fever,no paresthesias...and of course a high index of suspicion. Great question ditch doctor...thanks for posting!
Admittedly devlish. Hopefully, on the real exam we will probably get more clues such as recent camping, negative/equivocal CSF or intact sensation. I have been busted by this concept twice now on UW.
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| ditch doctor
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cyra wrote:
recognise the shorter time period in which the symptoms manifest for tick fever
Sorry, I'm not trying to be picky, but increased body temperature is not associated with tick paralysis/toxicosis.
So, "tick fever" would be an inaccurate description. "Tick fever" is another entity all together caused by a virus passed from the tick to the host.
Again Cyra, sorry, not to be picky... I just don't want anyone to get confused....
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| cyra
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oops!Dunno what I was thinking(or if I was thinking at all) when I typed "tick fever".Apologies for the mess up.
Thanks for the correction ditch doctor...much appreciated.You're very right... I also remember having read that if there is a history of fever or a prodromal illness then the Dx of tick paralysis is unlikely.
Edited by cyra on 07/14/06 - 08:04 AM
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| AAAAA
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She is working in a North Carolina barbecue restaurant and tells you that she had "food poisoning" about two weeks ago.
USMLE seldom mentions the location North Carolina, this is a giveaway. When ever they gave away the race, the location, Northeast, Southeast, Northwest, then it is tick !
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