A 20 year old boy from Salkunoor, Vemulapalli, Nalgonda presented with pain in the calves and weakness in his legs and feet since 30 days. The eldest of 3 children from a very supportive family, he reported that 20 days ago, on a sunny Saturday at 3pm, he decided to go for his weekly swim to a lake about 1km away from his home. Halfway through the journey with his friends, he started feeling cramping pain in his calves, which was unusual and over the course of the next 10 mins he developed weakness in his legs and feet and couldn't walk any further. Seeking relief under a tree's shade, the patient was aghast at his new onset disability. His friends too were surprised at his limitation. Realising that his power wasn't improving even with rest and with pain continuing, he was helped by friends, back home. He reported that at this time he had drenching sweats. He denied fever or loss of consciousness or syncope during this event. He also reported that he had a normal lunch before starting on his journey. After reaching home, he immediately went to bed. The mother was perplexed and concerned. After waking up, he noted difficulty in getting up from bed. He also reported that he was unable to get up or get down stairs. He did not report any history of buckling of his knees. He also had tingling in his feet but he says he is able to feel the surface his foot is on. He also says he can feel pain in his feet. He reports feeling cold water whenever he takes bath. No history of muscle contractures, stiffness of limbs, hypertrophied or atrophied muscles. He never had any difficulty in mixing his food, no difficulty in lifting heavy weights or combing his neatly crafted hair.
Over the course of the next 10 days, the power in his lower limbs improved, however his pain has more or less remained the same. At no point did he have a history of drooping of eyelids, double vision, severe burning pain in his arms or feet. The pain in his calves is short lasting, about 10 seconds and increases significantly with walking and standing. He has however been able to drive a motorbike today.
No history of chest pain, dyspnea, cough, palpitations, wheeze, pain abdomen, abnormal bowel habits, no history of incontinence or altered bladder habits.
A B.com student and the eldest to a younger brother and younger sister, he reports his distress has reduced with improving power. His mother confirms a full immunization history and an asymptomatic life prior to this event.
On examination:
Patient is conscious, coherent, thin built and moderately nourished.
Vitals:
Patient is Afebrile to touch
BP- 120/80 mm Hg
PR- 74 bpm
RR- 18cpm
No pallor , icterus, cyanosis, clubbing, generalised lymphadenopathh, pedal edema.
CNS EXAMINATION:
HIGHER MENTAL FUNCTIONS:intact
MOTOR SYSTEM:
Bulk right. left
Mid arm
circumference. 24cm 24.5cm
Forearm. 19.5cm. 18cm
Thigh. 37.5cm. 37cm
Leg. 28cm. 28.5cm
Tone: U/L Right and left normal
L/L reduced on both sides
Power: Right. left
U/L. 5/5. 5/5
L/L. 4/5. 4/5
ILIOPSOAS. 4/5. 4/5
ADDUCTOR F. 5/5. 5/5
GL. MEDIUS AND
MINIMUS 5/5. 5/5
GL. MAXIMUS. 4/5. 4/5
HAMSTRINGS. 3/5. 3/5
QUADRICEPS. 5/5. 5/5
FOOT AND DORSI. 3/5. 3/5
Reflexes. Right. left
Biceps. --. --
Triceps. -. -
Supraspinatus. - -
Knee. -- --
Ankle. -- --
Plantar. Babinski positive
On discharge plantar flexion on both the limbs
No spinal tenderness
SENSORY SYSTEM:
touch , pain, temperature present
Vibration and proprioception is lost in both the limbs.
CVS: S1 S2 Heard , No murmers
Respiratory system: bilateral air entry present, normal vesicular breath sounds heard
Per abdomen: soft, non tender.
The following investigations were done:
Nerve conduction studies were done:
Neurology consultation was taken likely to be GBS
lumbar puncture was advised but patient denied it
Diagnosis:
Bilateral severe lower limb >upper limb sensorimotor axonal neuropathy- AIDP/AMSAM
TREATMENT:
1) Tab.EVION 400 mg OD
2) Tab.NEUROBION FORTE PO/OD
3) PHYSIOTHERAPY OF LOWER LIMBS.
