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Case (2)


Mr Saleh Muse, a 39-year-old gas fitter, is admited to hospital because of rapidly progressive weakness.
He developed an odd tingling in his feet and legs earlier in the day and this worsened, as did the weakness.
He has now started to develop weakness in his arms. On examination, no reflexes can be elicited in the upper or
lower limbs and there is generalized, moderate, flaccid muscle weakness. Sensory examination is normal, despite the tingling in his legs. Over the next five days, serial measurements of his respiratory function show that the weakness is affecting respiration. He is put on a ventilator.
1 What is the diagnosis?

2 What is the pathogenesis of this condition?

3 What is the prognosis?
Who answer all these above questions correctly will be a warded 15 points immediately and we only accept one answer from each user?
who replies more than once will be kicked out from this competition!
The answers will be displayed after 7 days, then we choose the winner and lock the topic
By: Dr.Mahdi 8)

Assalamu calaykum.
           waxaan jeclaan lahaa inaan halkan kasoo jeediyo my provisional diagnosis of case 2.
         on the basis of history and examination you gave it's most likely to be *GUILLAIN BARRE SYNDROME*-GBS-.Also called Acute inflammatory or post-infective demylinating neuropathy this develops 1-4 weeks after respiratory infections or diarrhea in 70% of patients.
                 to confirm it i would like to do 1.CSF examination (to get protein cell dissociation)2.chest xray,stool culture,and appropriate immunological blood tests(to identify an underlying cause eg mycoplasma,cytomegalovirus or compylobacter.
      it is the most common acute polyneuropathy .it's usually demylinating(occasionally axonal) and propaply has an autoallergic basis. it's a monophasic illness-it doesnt recur. paralysis follows 1-3weeks after an infection that is often trivial,and often unidentified. compylobacter jejuni and cytomegalovirus are well known to cause severe GBS. the infecting organisms induce humoral responses against peripheral nerves. molecular mimicry between microorganism liposaccharides and ganlioside components of nerves is a potential mechanism of these cross reactions.
           Intravenous immunoglobulin  and plasma exchange if used with in first 2 weeks of developing the illness are equally efficient in reducing the severity and the duration of the disease.but there is no advantage in combining the two.
                        general measures to protect airway and prevent pressure sores and venous thrombosis is essential.
         Recovery begins(wheather or not treatment is given) between several days and 3 weeks from the outset.
             20% of patients develop respiratory and facial muscle involvement( as this case) where prolonged ventilation may be necessary.
        improvement towards independent mobility is gradual over many months; it may be incomplete.

The 15 points goes to Dr.Nasra because she gave the correct answer, second she is the only one who answred the case!
thanks Dr.Nasra and well done!!
1 Diagnosis

Guillain­Barré syndrome, or acute inflammatory polyradiculoneuropathy. This is the commonest form of acute neuropathy.
The marked slowing of conduction velocity in nerves is indicative of demyelination. The raised CSF protein
supports the diagnosis.

2 Pathogenesis

This is is an immune-mediated demyelination of peripheral nerves, usually seen 2­4 weeks after a viral illness,
 but also triggered after a variety of infective processes. Histologically, nerves show infiltration by lymphoid
cells with phagocytosis of myelin by macrophages. Patients have proximal as well as distal weakness because nerve roots are inflamed as well as peripheral nerves.

3 Prognosis

Widespread demyelination in peripheral nerves causes motor weakness, often leading to respiratory failure,
with less prominent sensory changes. If patients are ventilated and carefully nursed, remyelination usually
occurs over a period of several months, and is associated with recovery in most cases. Treatment with intravenous
immunoglobulin in the acute phase of disease reduces the severity of disease and shortens the duration illness.
Old age, the necessity for ventilatory support, and evidence of axonal degeneration on nerve conduction studies, are all adverse prognostic factors.
By: Dr.Mahdi


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