A. R., a 26-year old single female, from Manila was admitted for difficulty in walking.

About 6 days PTA, she experienced difficulty in walking such that she would walk with her slippers left
behind, and she would drag her feet. Over the next two days, this progressed such that when she would
squat on the toilet bowl, she would have difficulty in arising from this position. When she walked, she
noted unsteadiness and would buckle her legs so that she would suddenly fall.
On the day of admission, on waking up, she noted inability to stand up with both her legs barely
moving and with difficulty in climbing out of the bed, thus she sought confinement.
- No history of trauma
- No urinary or bowel complaints, still continent
- No history of fever
- No pains at the back
- No similar illness in the past
- No muscle pains
PMHx- she had asthma when she was a child, but by the time she was 12 years old there was no
recurrence of asthmatic attacks
FHx- no similar illness
PSHx- she has no vices, presently she is teaching in an elementary school in the city

F/N, F/D, carried per wheelchair, not in acute respiratory distress, conscious, coherent, oriented
to 3 spheres
BP- 100/80 HR- 83/min RR-20/min T- 36.5⁰C wt- 52 kg
HEENT- pink conjunctivae, anicteric sclerae, no NVE, no CLA, no tonsillopharyngeal congestion
Chest/lungs- equal chest expansion, clear breath sounds
Heart- PMI at the 5th ICS at the LMC line, RSR, no murmur
Abdomen- soft, flat, no organomegaly or tenderness
Extremities- good peripheral pulses, no edema
Neuro exam: MSE- awake, conscious, coherent, oriented
CN I-not tested
II- pupils 2-3 mm BRTL; no visual field cuts, no papilledema
III, IV, and VI- full EOM’s
V- no facial hemianesthesia
VII- she has incomplete closure of the eyelids, with difficulty in puffing her cheeks,
and she could not smile completely
VIII- intact hearing grossly
IX, X- good gag
XI- strong sternocleidomastoid muscles and good tone
XII- tongue midline
Sensory- about 20-30% sensory loss to pinprick on the dorsum of both feet up to the
distal legs, but intact vibration and position senses
Motor- shoulder abduction/elevation- 4/5 bilaterally
elbow flexion and extension- 5/5 bilaterally
wrist flexion and extension- 5/5 bilaterally
 hip flexion, extension, abduction and adduction- 3/5 bilaterally
knee flexion, extension, abduction and adduction- 2/5 bilaterally
foot flexion and dorsiflexion, abduction and adduction- 1/5 bilaterally
DTR’s- generalized areflexia
No Babinski or clonus
Neck supple, no meningeal signs
Autonomics- intact urination and bowel movement

Laboratory Examinations
CBC- Hb- 120 gm/L
Hct- 36 vol%
WBC- 7,100/cu. mm.
seg- 35% lymph- 60% eosino- 3% mono- 2%
platelet count- 185,000/cu. mm.
urinalysis- unremarkable
serum Na+- 138 mEq/L
serum K+- 3.8 mEq/L
serum Ca+2- 8.5 mEq/L
crea- 0.89 mg/dl
RBS-105 mg/dl
EKG- within normal limits
Chest X-ray- unremarkable
EMG-NCV- showed delayed nerve conduction velocities of the median and ulnar nerves
and of the tibial and peroneal nerves of the extremities, findings consistent with
demyelination.
Lumbar tap- opening pressure 75 mm H2O, clear, colorless
cell count- 2 cells counted
lymphos- 100%
protein- 1.5 gm/L
sugar- 65 mg/dl
gram stain- no pus cells; no organisms seen
culture/sensitivity- no growth after 5 days of incubation
India ink- negative for organisms
AFB smear- negative

While in the hospital, her condition worsened and complained of difficulty in breathing, so she
was placed on O2 inhalation. Aside from paralysis of the legs, she also could not lift her arms, with her
motor power of the arms and shoulders at 2/5 bilaterally. She developed mild tachypnea, but was still
conscious and coherent. However, on the 5th HD, she was diaphoretic with labored breathing, restless,
but still coherent and oriented. She was intubated and was put on ventilator.
ABG taken: During the 5th HD
Ph- 7.35 7.22
CO2- 38 66
O2- 89 54
 BE- 4.5 6.8
HCO3- 21 15
O2 sat- 95% 82%
Spirometry

The patient was given Immunoglobulin at 0.4 gm/kg/day at 20 gm as IV infusion for 5 days.
She also underwent physical therapy.
After the 5th HD, she was less dyspneic and was able to tolerate weaning from the ventilator
gradually. Day by day she improved such that her arms got stronger to 4/5 motor power, and her facial
diplegia has also improved, with ability to smile but still weakly, and she can close her eyeballs although
still not as strongly.
She was sent home after 25 days of stay with assisted ambulation, and was advised to continue
her physical therapy on an OPD basis.