Case Diagnosis: Primarily Motor Axonal Neuropathy
Case Description: 55-year-old male with history of hypertension, diabetes, and asthma, who suffered a gastrointestinal infection. Two weeks after patient presented with right lower extremity weakness progressing rapidly to involve the right upper extremity. Work-up for cerebrovascular accident including head CT and MRI, carotid Doppler, echocardiogram; came unremarkable. Lumbar puncture revealed albuminocytologic dissociation, serum anti-GM1 IgG elevated, 1:51200. Nerve conduction study revealed acute motor axonal neuropathy. Patient underwent therapy with intravenous immunoglobulins and intensive treatment in acute inpatient rehabilitation ward with excellent response. First Electrodiagnostic study 8 days after onset of hemiparesis not strictly met criteria for Acute Inflammatory Demyelinating Polyneuropathy. Study done two weeks later was remarkable for AMAN with more than 80% reduction in amplitudes, absence and latency prolongation of F-waves. Upon discharge from inpatient rehabilitation, patient’s functional status improved. He achieved antigravity strength in right hemibody, modified independence in transfers, and ambulated at least 250 feet with rolling walker.
This case represents a very rare clinical presentation of AMAN. This patient presented with a right-sided hemiparesis that mimicked a stroke, which ultimately resulted in a delay in diagnosis and management. In addition, patient presented with diminished but preserved patellar reflexes initially, which is also uncharacteristic of AMAN. There are very few reported cases in literature of AMAN presenting with hemiparesis. In this particular case, patient responded well with high intensity rehabilitation and intravenous immunoglobulins.
Atypical Guillain-Barre Syndrome may present with asymmetric weakness mimicking a stroke. Treatment with IVIG and intensive rehabilitation seems to improve functional outcomes.
Daniel Colon-Conde– Resident, VA Caribbean Healthcare System
Eduardo Maldonado-Colon– PM&R SENIOR RESIDENT, VA CARIBBEAN HEALTHCARE SYSTEM
Anelys Torres-Rivera– PM&R ATTENDING PHYSICIAN, VA CARIBBEAN HEALTHCARE SYSTEM
Irma Valentin-Salgado– PM&R ATTENDING PHYSICIAN, VA CARIBBEAN HEALTHCARE SYSTEM