GBS案例讨论及总结幻灯ppt(原创)

— NeuroMuscular Junction : Myasthenia Gravis
— Fatigue test (+) at four limbs.
— Neostigmin test : 1st (+/-), 2nd time (-)
— Try Piridostigmina 60mg tid po, no improved.
— Clinical feature
Lower Motor Neuron disease
— Acute onset + bilateral flaccid paralysis
— Differentia Diagnosis
— Acquired Neuropathies: Guillain–Barré Syndrome?
embolism and GBS? — 3. How to treat the patient who failure to IVIG
treatment ? Plasma exchange?
Guillain–Barré Syndrome
Guillain-Barré Syndrome, Review Article, N Engl J Med 2012 June;
— LP / CSF (17/6/2012): — Glicose(LCR) : H 4.80 mmol/l (2.20 - 4.20) — Protein (LCR) : 6.37 g/l (<0.45 g/L) — Aspect : Clear — Colour: Pinkish — Leukocytes: 2/ul — Erythrocytes: Many (+/- 100/ μL)
Upper Motor Neuron disease
Hyperactive ↑
Whole limb
Lower Motor Neuron disease
↓or No ↓
Distal>Proximal
Myopathy
Preserved Normal Proximal > Distal
Babinski sign Atrophy Sensory deficit Fasciculation CK enzyme
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Questions
— 1. Is it influenza vaccine the etiology of this patient? — 2. What’s the relationship between pulmonary
Physical examination
— BP 142/87mmHg, P 87/min, T 36.9C,conscious, no jaundice, AP(-), AC (-), ABD(-).
— Neurological examination: — Both pupils equal, 3 mm in diameter, reactive to light, neck soft, both eyes ptosis, could not whistle, slurred speech and difficulty in swallowing (bulbar palsy) -CN III, VII, IX palsy — Muscle power of four limbs decrease : both upper limbs: 1-2/5, both lower limbs: 0-1/5, DTR (-), pain stimuli feeling symmetry and exist at both limbs, muscle tone decrease, both Babinski's sign(-).
— Qualitative diagnosis: “What”
— Differential diagnosis
Localization diagnosis: “Where”
— “Quadriplegia”---Acute motor weakness
—
DTR(Reflexes ) Muscle tone Distribution
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Introduction
— Guillain-Barre´ syndrome (GBS) is an acute onset, immune-mediated disorder of the peripheral nervous system.
— Consulted ER on 12/6/2012 due to both upper limbs weakness for 1 week (since 5/6/2012), gradually involved both lower limbs.
— Brain CT(12/6/2012): a few lacunar infarction. — CXR(12/6/2012): lung marking increase. — Lumbar +thoracic spine X-ray(12/6/2012): unremarkable. — In ER, pt refused lumbar puncture and sign paper for discharged. — On 16/6/2012, pt came ER again , c/o limbs weakness deteriorate
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Exclusion of malignant disorders
— Blood tumor marker: — CEA, AFP, CA125, CA19.9,CA15.3 ,SCC(-)
— Chest Abdomen Pelvis CT :
— - Right pulmonary embolism evoked. — - Bronchiectasis in right upper and bilateral lower pulmonary
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Index
— Introduction — Epidemiology — Etiology — Clinical presentation — Diagnosis — Treatment — Prognosis
(+) No(*) May
No normal
(-) Present May present Present Normal
(-) Present
No No ↑
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Qualitative diagnosis: “What”
— Lower leg Doppler: no DVT was found.
Chest Abdomen Pelvis CT
— Right pulmonary embolism
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Diagnosis:
— 1. Guillain–Barré Syndrome — 2. Right pulmonary embolism
— Hx: progressive bilateral flaccid paralysis with sensory preserve
— Lumbar puncture, EMG , etc …
— Hyperthyroidism hypokalemia periodical paralysis
— Normal K+ and normal thyroid function
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Case presentation
— 66y/F, Hx of hyperthyroidism 20 yrs ago but already cured (detailed unknown). Annual seasonal influenza vaccine on 29/1/2012.
Brain CT (12/6/2012)
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CXR
(12/6/2012)
Lung markiห้องสมุดไป่ตู้g Increase.
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Comp exam (12/6/2012)
— Blood test: — Hemogram: unremarkable — CRP: 0.27 — Coagulation profile: unremarkable. — Biochemistry: Glu: 6.9, Normal liver and renal function, normal electrolyte level(K+:3.7 mmol/L), normal CK and LDH level. — Thyroid function: T3 :0.65 ng/mL (0.80-2.00) , T4 : 7.87 ug/dL (5.10 - 14.10), FT4: 1.44 ng/dL (0.93 - 1.70) , TSH: 3.33 mIU/L(0.27 - 4.20)
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Diagnosis
— 1. Diagnosis: general paralysis for study? — Localization diagnosis: “Where”
— Central or Peripheral neuropathy , myopathy?