What’s Your Diagnosis? Pediatric Acute Demyelinating Syndromes
February 22, 2021
Posted by Andy Jagoda MD in: What's Your Diagnosis , trackback
Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got last month’s case on An Evidence-Based Approach to Nontraumatic Ocular Complaints in Children right.
Case Presentation: Pediatric Acute Demyelinating Syndromes: Identification and Management in the Emergency Department
A 5-year-old boy presents to the ED with limping…
- The patient’s mother describes him as a healthy child who is up-to-date on vaccinations and has never required hospitalization. This morning, he was not as active as usual and stayed on the couch to watch TV. After lunch, she encouraged him to go outside and play, but he appeared to be dragging his feet and stumbling. She says that she had to assist him from the car to a wheelchair in the ED parking lot. When asked, the patient describes shooting, stabbing pain in his legs and says he is unable to walk. He denies trauma. He says the symptoms started this morning when he got out of bed, and that he has never felt this way before. The patient denies having a bowel movement today but does report normal morning urination.
- The patient is well-appearing, with normal mental status. The examination is significant for muscle strength 2/5 in the large muscle groups of his bilateral lower extremities, and the patient is not able to walk. He has absent deep tendon reflexes at the patellar and Achilles tendons, but sensation is intact. When asked about previous illnesses, the patient’s mother states that he was sick approximately 2 weeks ago with a “stomach bug.”
- What tests are indicated immediately? What interventions to prevent disease progression should be initiated in the ED? What is the appropriate disposition for this patient?
The boy was presumptively diagnosed with GBS based on the physical examination. A lumbar puncture confirmed the diagnosis with CSF protein/white blood cell count abnormalities (albuminocytologic disso- ciation). His respiratory status was monitored closely in the ED, and he was admitted to the ICU for 3 days while he received IVIG therapy. He responded well to treatment and was graduated from ICU to floor status on day 4 of hospitalization, and to inpatient rehabilitation on day 12 of hospitalization. At 6 months after diagnosis, he did not require a wheelchair for ambulation and was completing almost all of his activities of daily living with age-appropriate assistance.