December 2014 Critical Care Case of the Month: Weak for Weeks

Tuesday, December 2, 2014 at 8:00AM
Rick Robbins, M.D. in cholinergic crisis, corticosteroids, differential diagnosis, intravenous immunoglobulin, myasthenia gravis, myasthenic crisis, plasma exchange, pyridostigmine, treatment, work up

Bhupinder Natt MD¹

Shadi Koleilat MD²

Janet Campion MD¹

 

¹Division of Pulmonary, Allergy, Critical care and Sleep Medicine

²Department of Neurology

University of Arizona Medical Center

Tucson, AZ

 

History of Present Illness

A 65 year old woman presents with weakness involving both upper and lower extremities that is intermittent over the last 3 months, but in the last 2 weeks she has also noticed increasing neck weakness, droopy eyelids and increased drooling. Prior to this she was able to walk without difficulty and ride a recumbent bike for 20 minutes, but now is having difficulty walking on her own. She denies fevers, weight loss, shortness of breath, chest pain, palpitations, LE edema, joint pain, rash, any recent or current GI/GU symptoms and no new medications.

Past Medical History, Social History, and Family History

The patient has a past history of hypertension, hyperlipidemia, diabetes mellitus Type II, GERD, obstructive sleep apnea (compliant with BiPAP), atrial fibrillation and hypothyroidism. She has a 40 pack-year history of tobacco use. Family history is noncontributory.

Medications

• Dabigatran 75mg BID
• Esomeprazole 20 mg BID
• Furosemide 30 mg BID
• Insulin glargine 50 Units BID and Lispro per sliding scale
• Levothyroxine 88 mcg per day
• Losartan 50 mg QD,
• Pregabalin 75 mg BID
• Rosuvastatin 40 mg per day

Physical Examination

Vital signs: Afebrile. Pulse 86, respiratory rate 20, PaO2 92% on room air

General: Awake, fully oriented, dysarthric speech.

HEENT: Non-icteric, ears, nares, oropharynx unremarkable; there is no neck LAD, elevated JVP or thyromegaly.

Respiratory: Normal breath sounds, no wheeze or rhonchi.

CVS: Irregularly irregular rhythm, no murmurs. Peripheral vascular exam normal.

Abdomen: Obese, soft, non-tender with normal bowel sounds. No organomegaly appreciable.

Extremities: Trace pedal edema, normal muscle bulk and tone.

CN: Ptosis bilaterally, no nystagmus, reactive pupils, extra-ocular muscles intact, sensation intact, weak cheek puff, symmetric palate excursion, normal tongue protrusion.

Motor: Neck flexion and extension 4-/5, bilateral pronator drift, no focal lower extremity weakness, no muscle atrophy, no tremors or fasciculations.

Sensation: Intact to light touch hands and feet.

Reflexes: 2+ and symmetric throughout.

Gait: Wide-based and slow, can only walk short distances before experiencing bilateral leg weakness.

Laboratory: Normal electrolytes, complete blood count, and liver function tests. Creatinine mildly elevated at 2.1 mg/dL.

EKG

Atrial Fibrillation.

What is the most likely diagnosis? (Click on the correct answer to proceed to the next panel)

1. Guillain-Barré syndrome (GBS)
2. Hypothyroidism
3. Lambert-Eaton myasthenic  syndrome (LEMS)
4. Motor neuron disease (ALS)
5. Myasthenia gravis crisis

Reference as: Natt B, Koleilat S, Campion J. December 2014 critical care case of the month: weak for weeks. Southwest J Pulm Crit Care. 2014;9(6):302-8. doi: http://dx.doi.org/10.13175/swjpcc141-14 PDF

Article originally appeared on Southwest Journal of Pulmonary, Critical Care and Sleep (https://www.swjpcc.com/).