BOF: 16
A 40-year-old male presents with a 3-day history of
progressively worsening headaches, giddiness and seeing double. He also
complained of a dry mouth and difficulty swallowing.
His wife said that his face had looked asymmetrical over
the last few days.
He has no numbness or paraesthesiae. No gastrointestinal
symptoms.
Four days prior to onset of symptoms he head pricked
his finger on a bougainvillea thorn.
On examination, he was alert and orientated in place,
time and person. Pulse rate 62-beats/min regular, BP 120/80 mmHg, temperature
38.2° C.
CNS examination revealed ptosis, large poorly reactive
pupils
He had diplopia on looking to the extremities
horizontally (both sides)
There was difficulty in closing his eyes
He was unable to puff out his cheeks
He choked when asked to swallow water.
Power reduced in the upper limbs and lower limbs.
Deep tendon reflexes depressed
Sensation normal
The finger that had been injured looked red and inflamed
Investigations:
Hb 13.5g/dl
WCC 12.0 x 109/l
Platelets 200 x 109/l
Plasma sodium 138 mmol/l
Plasma potassium 4.2 mmol/l
Plasma urea 6.5 mmol/l
Plasma glucose 7.2 mmol/l
Lumbar puncture was performed
CSF showed
Opening pressure 14 cm H2O
Cell count <2 per mm3
CSF protein 0.2 g/l
CSF glucose 6.2 mmol/l
In this patient what is your most likely diagnosis?
a)
Guillain Barre syndrome
b)
Tetanus
c)
Myasthenia gravis
d)
Botulism
e)
Miller Fisher syndrome
