This case presentation describes a 30-year-old male who presented with gradual weakness in both lower limbs over 3 days. Initial treatment with analgesics and IV fluids provided no improvement. Nerve conduction studies revealed sensorimotor nerve affection in the lower limbs suggestive of Guillain-Barré syndrome. However, after admission the patient was found to be hypokalemic, which when corrected with IV potassium infusion resulted in rapid improvement of his weakness. Differential diagnoses discussed include various causes of secondary periodic paralysis and other entities that could cause acute generalized weakness.

1. By Mohamed Helal Ragheb Usama Ragab Yousif
Msc. Internal Medicine
Case Presentation
Is it simply GBS?

2. Gameel Mohamad Abdo 30 years old male, from Zagazig, Married and
have 3 offsprings the youngest is 10 years old, worker, no special
habits of medical importance and is right handed
Personal History

3. Complaint
Weakness of both upper and lower limbs of 3 days durat
ion

4. History of Present Illness
The condition started 3 days ago with gradual onset of weakness of
both lower limbs that was bilateral in lower limb more than upper li
mb, proximal more than distal, symmetrical.
The patient sought medical advice, receive treatment in the form of
analgesic antipyretics, IV fluids. No improvement was noticed, neurol
ogic consultation was done, advised NCV studies that was done and
reveled sensomotor nerve affection of lower limbs suggesting GBS f
or clinical correlation for which he was admitted to ZUH for further
workup.

5. History of Present Illness
After admission ABG was withdrawn and reveled hypokalemia that w
as corrected with IV potassium infusion. The next morning the patei
nt was well and good. Weakness improved, he was able to walk on
his own.

6. History of Present Illness (cont.)
No involuntary movement.
No symptoms suggest sensory affection.
No symptoms suggest cranial nerve affection.
No symptoms suggest increased intracranial tension.
No symptoms suggest speech affection.
No symptoms suggest sphincteric or sexual affection.
No symptoms suggest other system affection.

7. Past History
Diseases: Nil
Operations: Nil
Drugs: Nil

8. Family History
No similar conditions in the family
No positive consanguinity between both parents

9. General Examination
Patient is consciuos, GCS
•Eye movement: Eye to pain→ 4
•Speech: inappropriate words → 5
•Motor response: move to localize → 6
Vital Signs:
oBlood Pressure: 130/80
oPulse: 100, regular, equal on both sided, of average volume
oTemperature: 37.4ᵒ
c
oRespiratory rate: 14

10. General Examination (cont.)
Appearance: looks healthy
Built: average
Complexion: no pallor, no cyanosis, no jaundice, no pigmentation
Decubitus: lies flat on bed
Facial Expression: no characteristic facies
Head & Neck examination:
•Eyes: no pallor, no cyanosis, no jaundice, normal eye brows and lashes
•Hair: normal
•Nose: normal
•Lips: no pallor, no cyanosis, no signs of vitamins deficiency
•Parotid: not enlarged
•LN and thyroid: not palpable
•Neck veins: pulsating, no congested.

11. General Examination (cont.)
Extremities:
• Upper limbs: no clubbing, no pigmentations, no pallor, normal muscl
es and nerves.
• Lower limbs: bilateral lower limb edema up to knees, no pigmentatio
n.
Back: no pigmentation, no swelling, no spine deformities.

12. Examination (cont.)
Neurological examination
Mentality: patient is conscious.
Speech: no aphasia, no dysarthria
Cranial nerve examination:
•No abnormality was detected.
Sensory:
•Superficial sensation: intact.
•Deep sensation: intact.
•Cortical sensation: intact.

13. Examination (cont.)
Neurological examination (cont.)
Motor:
•Tone: normal.
•Power: 5/5 bilaterally
•Reflexes: normal
•No wasting, no deformity, no hypertrophy, no trophic changes, no invol
untary movements.
Plantar response: equivocal.
Cerebellar: no abnormality
Gait: normal gait.

14. Examination (cont.)
Cardiac examination
Inspection/Palpation: no precordial bulge, no pulsation, apex is normaly locat
ed in 5th space MCL, regular rate 100/min, no dullness outside the apex, no th
rill, no palpable sounds
Percussion: normal percussion notes
Auscultation: normal heart sounds, no additional sound, no murmur
Chest examination:
Inspection/Palpation: symmetrical chest, no bulge, no retraction, no visible v
eins, no pulsation, no deformity, normal TVF bilaterally.
Percussion: resonant except bare area of the heart.
Auscultation: normal vesicular breathing, no additional sounds (no crackles,
no rhonchi, bronchophony or aegophony.

15. Examination (cont.)
Abdomenal examination
Inspection: normal, normal hair distribution, no pigmentation, no hernial orific
es, as regard genitalia; no deformity, mild scrotal swelling
Palpation: no rigidity, no tenderness, no organomegaly, no plapable paraaortic
LN, no pulsation
Percussion: no shifting dullness, no organomegaly with percussion
Auscultation: normal intestinal sound, no bruit or venous hum.

16. Investigations
CBC: (8- 12.7- 281)
INR: 1.1
LFT :
Bilirubin: ,32/,13
Albumin 3.9 Total protein:5,6
AlT: 24 AST: 16
Creatinine: 0.63
Elctrolytes: Hypokalemia

19. Nerve conduction study
• Sensori motor axonal polyneuropathy Q (GBS).

21. T.S.H: 0.01

22. • Neurology consultation
They suspect GBS and recommend plasmaapharesis as line of treatmen
t together with supportive measures.

23. Treatment
• Potassium supplementation.
• Nursing care.

24. Differential Diagnosis (Secondary Periodic Paralyses)
Hypokalemic Hyperkalemic
Urinary potassium-wasting syndromes
•Hyperaldosteronism
•Conn syndrome
•Bartter syndrome
•Licorice intoxication
Alcohol
Addison disease
Chronic renal failure
Hyporeninemic
Hypoaldosteronism
Drugs - Amphotericin B, barium Ileostomy with tight stoma
Renal tubular acidosis Potassium load
GI potassium-wasting syndromes
•Laxative abuse
•Severe diarrhea
Potassium-sparing diuretics

25. Differential Diagnosis (Secondary Periodic Paralyses)

26. Differential Diagnosis (Other Entities Causing Acute Generalized Weakness)
Transient ischemic attacks
Follow CNS distribution (ie, hemiparetic)
May have sensory symptoms and signs
Sleep attacks
Occur at onset or termination of sleep
Last only minutes
Myelopathy
•Traumatic
•Transverse myelitis
•Ischemic
Sensory symptoms
Presence of a sensory level
Sphincter involvement
Myasthenia gravis
Lambert-Eaton myasthenic syndrome
Subacute in onset
Associated autonomic symptoms in LEMS
Hyporeflexia in LEMS
Abnormal repetitive nerve stimulation
Presence of distinct antibodies
•Peripheral neuropathy of acute onset
•Acute inflammatory demyelinating poly-r
adiculoneuropathy
•Porphyria
Pattern of weakness
Absent stretch reflexes

27. What about thyrotoxic paralysis

28. Thank you