K A T I E Q U A Y L E P G Y 2

A U G U S T 2 0 1 4
Morning Report
HPI

2 year old girl with difficulty walking for one day

Day prior to admission talking softly like a whisper

Decreased PO intake went to !e earlier than normal

Day of admission she was taking a !ath asked to !e

carried

"hen father put her down she fell forward into wall
without catching herself

#ould not !ear weight refused to walk

#omplained of di$$iness
%ackground

PMH& Healthy full term had caps put on teeth one month ago' was
seen at (D one year ago for accidental ingestion of grandparent)s
medication

Meds& *one

Imms& +p to date

De,elopment& -peech delay seen !y DDI ,antage

.H& Hypertension in father

-ocial& /i,es at home with parents 0 year old !rother1 2 older half
si!lings at home part time1 Mother !eing treated for li,er failure
secondary to alcoholism1 2apor cigarettes at home !ut are kept up
high1 Multiple medications at home !ut are locked up per father1

RO-& decreased PO refusal to walk soft ,oice1 *egati,e for diarrhea

fe,er ,omiting cough1
Physical (3am

4 5615 HR 780 RR 27 %P 772967 -aO2 :0; on R<

"eight 721= kg Height =: cm

>(*& awake alert interacti,e lying in !ed

H((*4& normocephalic atraumatic (OMI pupils dilated to 5mm !ilaterally !ut !riskly
responsi,e to light fluid !ehind right 4M !ut no distortion of landmarks mildly erythematous
pharyn3 !ut no palatal petechiae normal tonsils no cer,ical adenopathy' lips dry

#2& tachycardic regular -7 -2 no murmur distal pulses palpa!le cap refill 5 seconds distally

R(-P& clear to auscultation !ilaterally no whee$es crackles or difficulty !reathing

<%D& soft non?tender no H-M no re!ound

-@I*& mottled appearance scattered scrapes9!ruises on shins !ilaterally

*(+RO& interacti,e oriented to self appears to understand con,ersation and can respond
appropriately1 Palate ele,ates symmetrically1 4ongue protrudes midline1 4one is decreased
especially nota!le with head lag1 Muscle !ulk is normal1 -trength seems normal !ut she is not
cooperati,e at all to detailed e3amination1 Refle3es are diminished !ut present in the upper and
lower e3tremities !ilaterally1 *o clonus1 -ensation is intact to light touch in all 8
e3tremities1 <!normal coordination due to past?reaching for o!Aects presented to her1 -he
acti,ely tries to lay !ack down when placed into a seated position1 -he a!solutely refuses to
stand1
2 year old pre,iously healthy girl presents with acute
onset of ata3ia hypotonia and refusal to !ear weight
Differential

ID

4ick paralysis

Polio

/yme disease

%otulism

Diphtheria

2iral myositis

HI2

(pidural a!scess

Infectious causes of acute myelitis Beg "est *ile ,irus

co3sackie,iruses echo,irusesC

*euro

%ilateral stroke

Intracranial hemorrhage

<cute cere!ellar ata3ia syndrome

Posterior fossa structural lesion

<D(M

4rans,erse myelitis

<nterior spinal artery syndrome

Myasthenia gra,is

#ompressi,e spinal cord lesion

M-

>%-

Meta!olic

(lectrolyte im!alances& hyper or

hypokalemic

Other

4o3ic neuropathy& lead hea,y metal

,incristine

(3posure to organophosphates
pesticides

Ingestion& alcohol amiodarone lyrica

ati,an phenytoin

Puffer fish to3icity

Prophyria

Hysterical paralysis

Meta!olic and inflammatory myopthaies

*<4

-ystemic ,asculitis

#ritical illness polyneuropathy

Initial "ork +p

/a!s&

+<& pH D1D spec gra, 71E7D neg glucose9nitrites9protein9leuk esterase 7F ketones

+rine drug screen negati,e

-erum drugs of a!use screen negati,e

#%#& "%# 6 Hg! 78 Hct 8E Plts 56E' *86 /88 M6

#MP& *a 750 @ 817 #l 7E0 #O2 7: %+* 77 #r E15D glucose 6: #a 7E15 Protein 618 <l!
818 4!ili E16 <lk Phos 2=0 </4 2E <-4 52

Imaging9other&

#4 Head without contrast & *o e,idence of acute intracranial pathology

(#>& -inus tachycardia

Pending& /yrica le,el Guant !en$os

#onsultants&

4o3icology& story concerning for ingestion1 Recommended sending dilantin le,el as

presentation is classic for dilantin ingestion1 #ould also !e consistent with lyrica or
ati,an ingestion1
<nchoring (ffect
Hospital Day 2

*ow reGuiring H?798/ o3ygen to maintain sats

"orsening weakness

Increased oral secretions continued refusal to eat

Had couple episodes of sweating

#ontinued tachycardia despite multiple fluid !oluses

Decided to consult neurologyI

.urther "ork +p

#-.& 2"%# and J7R%# glucose D= protein D5

%rain MRI&

Kuestion su!tle focus of demyelination ,ersus possi!le artifact

within the cer,ical cord at le,el of #5 seen only on the sagittal
42 .-( seGuence1

MRI spine&

*o e,idence of demyelinating disease1 *o specific etiology

identified to correlate with symptomatology1

-ignificantly distended and fluid?filled !ladder

Diagnostic -tudy

(M> performed

#onsistent with >uillain?%arre syndrome

>uillian?%arre -yndrome

Polyradicuoneuropathy

Most common cause of flaccid paralysis in kids

E18?715 cases per 7EEEEE per year

#linical&

Progressi,e symmetrical ascending weakness

<!sent refle3es

Diffuse pain common

-e,eral 2ariants

<cute inflammatory demyelinating polyneuropathy

<cute motor a3onal neuropathy

<cute motor?sensory a3onal neuropathy

Miller .isher syndrome

Pathogenesis

<!normal immune response to an antecedent e,ent

295 of patients report resp9>I illness in weeks prior

to symptoms

L Relationship to ,accines
Diagnosis
MDue to copyright
restriction the ta!le
cannot !e pu!lished in
the presentation1

-igns and -ymptoms of >uillain?

%arrN -yndrome ta!le found in
Pediatrics in Re,iew article

Guillain-Barr Synro!" 55B8 C

708?7671
Diagnosis
MDue to copyright
restriction the ta!le
cannot !e pu!lished in
the presentation1

Differential Diagnosis of
>uillain?%arrN -yndrome ta!le

.actors 4hat #ast Dou!t

on Diagnosis of >uillain?%arrN
-yndrome ta!le

4a!les found in Pediatrics in Re,iew

article& Guillain-Barr Synro!"
55B8C 708?7671
Diagnosis

Made clinically

History of prior respiratory or >I illness

Refusal to walk

Pain

<utonomic insta!ility

Most useful tests to get

#-.

(M>

#onsider MRI

#onsider getting anti?>M anti!odies

4reatment and Prognosis

Prognosis

>enerally ,ery good

4reatment

Monitoring and supporti,e care

I2I>

Plasma e3change

"hen to send to PI#+L

Rest of #ourse

2 gm9kg I2I> di,ided in 2 doses

"eaned off O2 #%> followed without signs of #O2 retention

Had neuropathic pain?Oga!apentin started

*> placed for feeds

PM*R consulted

>M anti!odies came !ack positi,e

Discharged D9=& Her strength is much impro,ed and she is walking

independently with hand hold assist for safety1

Her last swallow study prior to discharge showed silent aspiration of thin
liGuids1 "ent home on a mechanical soft diet with honey thick liGuid !y
straw' howe,er father reports that she is often getting other foods from her
si!ling and is eating #heetos and other items as well as drinking fluids
including occasionally drinking water out of the dog dish1

697E& *ormal neuro e3am all intake !y mouth passed swallow study
References

+ptodate

Rosen %eth <1 >uillian?%arre -yndrome1 Pediatrics

in Re,iew1 2E72'55'7081