2. Symptoms  Chief Complaint = “I am getting weak”  Painful sensations with increasing muscle weakness in both LE (started in ankles)  Prickly numbness and tightness in lower abdomen

3. H & P Findings  Coronary Artery Disease  Campylobacter jejuni diarrhea a few weeks ago, successfully treated with antibiotics  Smokes 1 ppd  Vitals Normal except BP Δ from 130/80 to 90/60 when going from supine to standing.  Absent patella and achilles reflex  Decreased pain and touch in feet  Decreased proprioception in LE

5. Our Differentials  Diabetes  Herniated Disc  Neoplasia  Lead Poisoning  Demyelinating Disease

7. Diabetic Peripheral Neuropathy  Diabetic nerve pain result of damage to nerves because of high blood sugar levels over time.  Can affect any nerves and thus a list of possible symptoms, but usually develop over a number of years.  Causes; Not totally clear Believed to be a number of contributors ○ Metabolic, neurovascular, autoimmune factors ○ Mechanical injury to nerves, inherited traits, or lifestyle factors

8. Diabetic Peripheral Neuropathy  Symptoms that Correspond painful sensations and increasing muscle weakness of both lower extremities. has difficulty rising from a chair, climbing stairs, and complains of an unsteady gait. a prickly numbness in both legs and a band-like tightness across his lower abdomen indigestion, nausea, or vomiting diarrhea or constipation loss of reflexes

9. Diabetes  Hemoglobin A1C - $37 On high side of normal range 6.1 (3.8-6.4)

11. Herniated Disc  Bulging of nucleus pulposus, with or without nerve root compression  Most common in lumbar region  Symptoms: Back pain Leg pain  Occurs mostly in 30’s and 40’s

12. Herniated Disc  Patient’s symptoms consistent with disc herniation: Painful sensations in LE Tingling sensations in LE Muscular weakness in LE

13. Herniated Disc  Patient’s symptoms inconsistent with disc herniation: Bilateral LE pain uncommon 25 y/o Ataxia

14. Herniated Disc  X-ray of LS spine - $190 Normal  MRI spine - $1400 normal

16. Cauda Equina Syndrome  Compression of large nerve trunks Tumor, infection, narrowing of spinal canal

17. Cauda Equina Syndrome  His symptoms that correspond Progressive loss of sensation Muscle weakness

18. Cauda Equina Syndrome  His symptoms that don’t correspond Bowl or bladder dysfunction No muscle atrophy

19. Neoplasia – Cauda Equina Syndrome  MRI spine - $1400 normal

21. Lead Poisoning  Occupational Hazard: potential lead exposure  His symptoms that correspond Pain, numbness, and tingling in the extremities Muscle weakness Abdominal Tightness

22. Lead Poisoning  Headache  Memory Loss  Mood Disorder

23. Lead Poisoning  Blood lead test Normal range for unexposed individual

25. Demyelinating Disease  Blood Glucose 87 (70-110)  LP Normal CSF glucose 100 ( > 2/3 BG) and high CSF protein 85 (25-45)  EMG – nerve conduction 40% slowed nerve conduction in legs. Indicates proximal demyelination

27. Guillain-Barre Syndrome  General information: Immune system attacks peripheral nerves ○ Antibodies generated for C. jejuni attack gangliosides in PNS Ascending starting w/ weakness and tingling in legs Potential to ascend to C3-5 and affect diaphragm/respiratory innervations Rare 1:100,000 affected Recovery ranges from weeks to a few years

28. Guillain-Barre Syndrome  National Institute of Neurological Disorders and Stroke (NINDS) Diagnostic Criteria 1 : Required Features: ○ Progressive weakness of more than one limb, ranging from minimal weakness of the legs to total paralysis of all four limbs, the trunk, bulbar and facial muscles, and external opthalmoplegia ○ Areflexia. While universal areflexia is typical, distal areflexia with hyporeflexia at the knees and biceps will suffice if other features are consistent Supportive Features: ○ Progression of symptoms over days to 4 weeks ○ Relative symmetry ○ Mild sensory symptoms or signs ○ Elevated CSF protein with a cell count <10mm3 ○ Electrodiagnostic abnormalities consistent with GBS

29. Guillain-Barre Syndrome  Patient: Dx High CSF protein w/o increased cell count EMG showing conduction slowing and loss of F waves Commonly follows infection ○ camplyobacter jejuni, CMV, Epstein-Barr, herpes, and viral hepatitis U.K. study showed that 26% of GBS affected Pts had evidence of a recent C. jejuni infection 2 Swedish study estimated that the risk for developing GBS within two months of C. jejuni infection was 100x higher than risk in general population 3 Orthostatic hypotension (130/80 to 90/60 )

30. Guillain-Barre Syndrome  Acute inflammatory demyelinating polyneuropathy Most common form of GBS in the United States and Europe, representing 85-90% of cases. Earliest abnormalities see on clinical neurophysiology studies are prolonged or absent F waves, reflecting demyelination at the level of the nerve roots. 4

31. Treatment  No known cure  High dose of intravenous immunoglobin (IVIG) therapy or plasma exchange therapy Equally beneficial with no apparent benefit of combining the two therapies  Long-term management of neuropathic pain tricyclic antidepressants, gabapentin, carbamazepine  Monitor for progression of disease

32. What bacterial infection commonly precedes Guillain Barre? A. Strep agalactiae B. C. jejuni C. Epstein Barr D. Cryptococcus E. Serratia Marcescens

33. Which of these can cause peripheral neuropathy? A. Diabetes B. Lead Poisoning C. Cauda Equina D. Guillain Barre E. All of the above

34. What is the treatment method for Guillain Barre? A. Surgery B. Blood Transfusion C. Plasma Exchange D. Amputation E. All the above

35. Sources  1. Criteria for diagnosis of Guillain-Barre Syndrome. Ann Neurol 1978; 3:565.  2. Rees, JH, Soudain, SE, Gregson, NA, Hughes, RAC. Campylobacter jejuni infection and Guillain-Barre Syndrome. NEngl J Med1995; 333:1374.  3. McCarthy, N, Giesecke, J. Incidence of Guillain-Barre syndrome following infection with Campylobacter jejuni. Am J Epidemiol 2001; 153:610.  4. Gordon, PH, Wilbourn, AJ. Early electrodiagnostic findings in Guillain-Barre Syndrome. Arch Neurol 2001; 58:913.