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Thread: case discussion: Acute Muscle Weakness

  1. #1
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    Mar 2007
    Leeds, United Kingdom
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    Lightbulb case discussion: Acute Muscle Weakness

    Acute Muscle Weakness

    Trigger 1:
    Zainab a 30-year-old female was brought to the ER with inability to stand & talk since the morning. She had performed Umra 3 weeks ago and has been recovering from an upper respiratory tract infection that she came back with. She had no fever but she complained of deep pain in her thigh and calf muscle.

    Trigger 2:
    General examination demonstrated a body temperature of 37.2 C, 70 ∕ bpm heart rate, 115 ∕ 80 blood pressure in the sitting and standing positions. Cranial nerves examination demonstrated mild bilateral weakness involving the whole face. There were no features of ophthalmoparesis, papillary disturbances, dysphagia nor dysarthria.

    Trigger 3:
    Motor system assessment revealed weakness of the four limbs with grade 2∕5 power in the lower; and 4∕5 in the upper limbs (Medial Research Council scale). Passive limb movements showed marked hypotonia. Deep tendon reflexes were absent in the lower limbs but only reduced in the upper limbs.

    Trigger 4:
    Sensory system was within normal. Coordination was preserved in the upper limbs. Gait was not assessable. There were no signs of autonomic nervous system dysfunction. Examination of the heart, respiratory system and abdomen were normal. The urinary bladder was not distended and the sphincter functions were intact. A provisional diagnosis of acute polyneuropathy was made.

    Trigger 5:
    Zainab was admitted to the medical ward for more assessment and surveillance of her respiration and bladder functions. Pulmonary function tests showed normal forced vital capacity and FEV1. results of biochemical investigations showed normal complete blood count (CBC), liver function tests (LFTs), renal function tests (RFTs), & serum Ca, Mg, Ph and creatine kinase.

    Trigger 6:
    Nerve conduction studies (CNS) and electromyography (EMG) revealed prolonged distal motor latencies (DMLs), reduced motor conduction velocities (MCVs) and reduced compound muscle action potentials (CMAPs).
    A lumbar puncture (LP) was performed. The cerebrospinal fluid (CSF) revealed an opening pressure of 150 mm with crystal clear appearance, WBC 2∕mm 3, protein 100 mg ∕dl and glucose 70% of a simultaneously obtained random blood glucose.

    Trigger 7:
    A diagnosis of acute inflammatory demyelinatimg polyneuropathy (AIDPN) or Guillain Barr'e syndrome (GBS) was made. A 4-day course of intervenous immunoglobulin was started at a dose of 0.4 G ∕kg daily. Physiotherapy was initiated and zainab started to improve gradually. She was able to walk with support when discharged home three weeks later. Zainab was asked to continue physiotherapy and rehabilitation as an outpatient.


    - infection (bacterial, tuberculous, fungal, viral meningitis) suspected
    - subarachnoid hemorrhage (SAH) (since CT negative in 10% of SAH)
    - non-infectious inflammation (SLE)
    - CSF chemistry for diagnosis (gammaglobulin oligoclonal banding for MS)
    - CSF dynamics (e.g. NPH or spinal block)
    - cytology (e.g. carcinomatosis, meningeal cancer)
    - therapeutic intrathecal drug administration
    - therapeutic removal of CSF (e.g. pseudotumour cerebri)
    - diagnostically for contrast injection during myelography
    - inflammatory polyneuropathy (e.g. Guillain Barre syndrome)

    #signs and symptoms of increased ICP (papilledema, decreased LOC, progressive deficit, headache)
    due to mass lesion
    • do CT first and then proceed to lumbar puncture (LP) if there is no shift
    # neurologic findings suggestive of localized mass lesion
    # obstructive hydrocephalus, or evidence of blood
    # infection at LP site
    # coagulopathy (e.g. anticoagulatn drugs) or thrombocytopenia
    # developmental abnormality (i.e. tethered spinal cord)

    Diagnostic Tests
    * opening pressure, protein, glucose, cell counts, colour, VDRL, viral PCR, IgG levels, oligoclonal bands,
    fungal antigens, microbiological stains (Gram, ZN, fungal), bacterial culture and PCR


    # most common is bifrontal or generalized headache (10-40%)
    # tonsillar herniation
    #spinal epidural hematoma


    GBS is a heterogeneous grouping of immune-mediated processes generally characterized by motor, sensory, and autonomic dysfunction.

    In its classic form, GBS is an acute inflammatory demyelinating polyneuropathy characterized by progressive symmetric ascending muscle weakness, paralysis, and hyporeflexia with or without sensory or autonomic symptoms; however, variants involving the cranial nerves or pure motor involvement are not uncommon.

    In severe cases, muscle weakness may lead to respiratory failure, and labile autonomic dysfunction may complicate the use of vasoactive and sedative drugs.


    Bacterial infections include (C jejuni, Haemophilus influenzae, Mycoplasma pneumoniae, and Borrelia burgdorferi).

    Viral infections include (cytomegalovirus, Ebstein-Barr virus, and during seroconversion with the human immunodeficiency virus (HIV).


    Medications (antimotility drugs and penicillins more often and oral contraceptives less often, streptokinase, isotretinoin, danazol, captopril, gold, heroin, and epidural anesthesia among others).

    Anecdotal associations include systemic lupus erythematosus, sarcoidosis, lymphoma, surgery, renal transplantation, and snake bite.

    Possible complications of GBS include the following:

    -Persistent paralysis.

    -Respiratory failure, mechanical ventilation.

    -Hypotension or hypertension.

    -Thromboembolism, pneumonia, skin breakdown.

    -Cardiac arrhythmia.



    -Urinary retention.

    -Psychiatric problems such as depression and anxiety.

    -Nephropathy reported in pediatric patients

    Nerve conduction test:

    Alternative Names
    Nerve conduction velocity (NCV)
    Definition :***
    is a test of the speed of signals through a nerve.
    Test procedure :
    Patches called surface electrodes, similar to those used for ECG, are placed on the skin over the nerve at various locations. Each patch gives off a very mild electrical impulse, which stimulates the nerve.

    The nerve's resulting electrical activity is recorded by the other electrodes. The distance between electrodes and the time it takes for electrical impulses to travel between electrodes are used to determine the speed of the nerve signals.

    This test is used to diagnose nerve damage or destruction. Occasionally, the test may be used to evaluate diseases of nerve or muscle .
    Normal Result:
    NCV is related to the diameter of the nerve and the normal degree of myelination (the presence of a myelin sheath on the axon) of the nerve .

    Electromyography (EMG)

    Definition :
    is a test that assesses the health of the muscles and the nerves controlling the muscles.

    Test procedure :

    For an EMG, a needle electrode is inserted through the skin into the muscle. The electrical activity detected by this electrode is displayed on an oscilloscope, and may be heard through a speaker.

    After placement of the electrodes, you may be asked to contract the muscle (for example, by bending your arm). The presence, size, and shape of the wave form -- the action potential -- produced on the oscilloscope provide information about the ability of the muscle to respond when the nerves are stimulated.


    EMG is most often used when people have symptoms of weakness and examination shows impaired muscle strength. It can help to differentiate primary muscle conditions from muscle weakness caused by neurologic disorders.

    Normal Result:

    Muscle tissue is normally electrically silent at rest. Once the insertion activity (caused by the trauma of needle insertion) quiets down, there should be no action potential on the oscilloscope. When the muscle is voluntarily contracted, action potentials begin to appear. As contraction is increased, more and more muscle fibers produce action potentials until a disorderly group of action potentials of varying rates and amplitudes (complete recruitment and interference pattern) appears with full contraction.
    Never Let Student Die In Your Heart When It Dies You Want Remain A Doctor But You Will Be A Technician

  2. #2
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    Jan 2007
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    Interesting article... Thanks!

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