Aashi
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A 45-year-old man presented with diplopia, dysarthria and difficulty with swallowing. Over the next few days he developed weakness of the upper and lower limbs. On day 4 he was unable to walk unaided. He denied any sensory symptoms or bladder disturbances. His previous medical history is unremarkable. He is a non-smoker, does not drink alcohol excessively. He does not take any drugs On examination he was apyrexial. His general medical examination was normal. His higher mental function was unremarkable. There were no signs of meningism. Cranial nerve examination showed bilateral dilated and fixed pupils. He had binocular diplopia but no obvious ophthalmoplegia. He was dysarthric with weak cough. His vital capacity was 3.15 standing and 2.00
lying flat. He had lower motor neuron tetraparesis of power 3/5. He was hyporeflexic with normal sensation. He was unable to walk unaided. Blood tests including FBC, U+Es, LFTs, TFTs, Ca, Autoantibody screen, ESR, CRP were normal. ECG and CXR were unremarkable. CT brain was normal. Nerve conduction studies and EMG were normal. What is the most likely diagnosis?
1 ) Guillain Barre Syndrome
2 ) Lyme disease
3 ) Myasthenia gravis
4 ) Botulism
5 ) Vasculitis
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| MDcooper
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auroantibodies negative=rules out mysthenia
no previous infection with campylo+proximal weakness first is not there=rules out guillian barre
vasculitis is also unlikely with the presentation.
lymes and botulism can be the possibilities.Lymes is unlikely as no tick bite or travel in woods mentioned.It wont happen at home.
it has to be botulism.
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| Aashi
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EMG in botulism is very typical --> Increment of muscle contractions with repeated nerve stimulation( same with eaton -lambert)..something opposite to MG..but here EMG is normal 
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| MDcooper
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EMG is typical but is it highly sensitive and specific?I think the diagnosis is via botulism toxins not EMG.
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| robin082006
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I GO WITH BOTULISM TOO. THANKS FOR GOOD QUESTION.
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| robin082006
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BUT SYMPTOMS ARE TYPICAL OF GUILLAIN BARRE.
CAN WE RULE OUT IT BECAUSE THERE IS NO HISTORY OF INFECTION AND NEGATIVE ANTIBODY?
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| sarika
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its not ascending paralysis..so im not sure abt GBS.
puely on the basis of exclusion we can go with vasculitis
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| Aashi
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Yeah robin,even i think the answer is GBS- though most o fthe time we do have bilateral areflexic limb weakness( ascending) but,sometime we do have decending limb paralysis ( Cranial nerve palsies (III-VII, IX-XII) may be present. Patients may present with facial weakness mimicking Bell palsy, dysphagia, dysarthria, ophthalmoplegia, and pupillary disturbances. The Miller-Fisher variant is unique in that this subtype begins with cranial nerve deficits. )..well its a good q, and its really tricky..EMG is the only way u can diffrentiate b/w BOTULISM, EL syndrome and MG...well in GBS we do a LP( high protein without pleocytosis is characterist) and EMG can be rarely NORMAL IN GBS
So I think its GBS
Edited by Aashi on 01/10/07 - 06:38 AM
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| prathapdoctor
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I will go with botulism.
ESR normal and vasculitis generally cause mononeuritis multiplex,even in that condition the abnormailty will be detected by nerve conduction studies.
autoantibodies are negative and EMG studies are normal so i will rule out Myasthenia.
no previous history of upper respiratory or gastrointestinal inf, in gullian barre,the nerve conduction studies will be abnormal and show decreased conduction so i will rule out Gullian barre.
lymes disease is a possiblity but there was no history of preceeding infection,no history of fever,normal ESR and i have never heard of lymes disease causing this kind of gen lower motor polyneuropathy without effecting sensory system.
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| fox
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what is TFTs?
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| Guptashutosh
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tft is thyroid funtion test..
i`ll got with botulism toooooo
emg is a distractor
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| star1
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It cant be GBS as two things go aganist this in the vignette
1-Sensory system normal
2-EMG normal
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