(468) The Only Way Back Down Is by Going Up: An Atypical Case of Ascending Paralysis

Introduction: Acute myopathy in hospitalized patients is relatively common, but delineating the underling etiology of the weakness can be challenging as it may be secondary to conditions such as inflammatory, infectious, drug-induced, metabolic, critical illness and/or immunological. One of the most common causes of acute myopathy, Guillain-Barré Syndrome (GBS), can be especially arduous to diagnose given the disease heterogeneity and numerous variant forms.

Description: A 74-year-old woman with a complex history including chronic pancreatitis requiring multiple surgical procedures including pancreatectomy and eventual multivisceral transplant including partial stomach, duodenum, small bowel and pancreas. She was electively admitted for surgical management of recurrent diverticulitis with a sigmoidectomy and colorectal anastomosis. She improved postoperatively, tolerated diet, and approached discharge. On postoperative day 12 she unexpectedly developed weakness in her bilateral upper extremities (UE), but head CT was negative for stroke. The following day her UE weakness had worsened, and the weakness now involved her lower extremities. It was acutely ascending, necessitating intubation due to respiratory failure. Further work up including MRI, bloodwork, chest CT, and LP were not suggestive of infection, GBS, malignancy, or Myasthenia Gravis. An EMG was later performed which was most consistent with acute axonal sensorimotor neuropathy, and neurology diagnosed her with Axonal GBS or a diffuse inflammatory post-surgical neuropathy. She was started on IVIG which resulted in a dramatic improvement of symptoms and weaning from mechanical ventilation. Although she had a tracheostomy by this time, she was weaned to trach collar and ultimately decannulated after the IVIG therapy initiation.

Discussion: Neuromuscular weakness in hospitalized patients can be a diagnostic dilemma, and it necessitates an aggressive, thorough history, physical examination, and work-up. Acute myopathy can be life threatening due to the underlying etiology and/or respiratory failure if not recognized. Axonal GBS requiring intubation, while rare, is an example of a life-threatening myopathy carrying the potential for rehabilitation and recovery, further emphasizing the importance of a thorough workup and an expeditious diagnosis.