A Case of GBS - Lower Cranial Nerve Variant

AN INTERESTING CASE OF DIPLOPIA PROF. P. VIJAYARAGHAVAN’S UNIT (M4 UNIT) DR. STALIN

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H/O Present illness ,[object Object],[object Object],[object Object]

PAST HISTORY; ,[object Object],[object Object],[object Object],[object Object]

PERSONAL HISTORY ,[object Object],[object Object]

FAMILY HISTORY ,[object Object],[object Object]

GENERAL EXAMINATION ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Systemic examination ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CNS EXAMINATION ,[object Object],[object Object],[object Object],[object Object],[object Object]

MOTOR SYSTEM RIGHT LEFT UPPER LIMB LOWER LIMB UPPER LIMB LOWER LIMB BULK NORMAL NORMAL NORMAL NORMAL TONE NORMAL NORMAL NORMAL NORMAL POWER 5/5 4/5 (PROX>DIST) 5/5 4/5 (PROX>DIST) DEEP TENDON REFLEXES + ++ + ++ PLANTAR FLEXOR FLEXOR

CRANIAL NERVES; ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Right abducent palsy Lool left Look straight Look right

Sensory system CORTICAL SENSATION - NORMAL ROMBERG'S – UNSTEADINESS BOTH EYES OPEN & CLOSED RIGHT LEFT UL LL UL LL PAIN NORMAL NORMAL TEMPERATURE NORMAL NORMAL TOUCH NORMAL NORMAL VIBRATION NORMAL NORMAL POSITION NORMAL NORMAL

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Possible structures involved ,[object Object],[object Object],[object Object]

Diagnosis with differentials: ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Normal symptom Mitochondrial myopathy MS / ADEM Botulism Viral encephalitis Tick paralysis diphtheria Weakness Hemiparesis/ recurrent prox flaccid quadriparesis Pyramidal hemi/quadriparesis Flaccid quadriparesis, descending Focal, pyramidal Flaccid quadriparesis, ascending Flacid quadriparesis, descending Cranial nerves Only ocular Any cranial nerve Pupils, any cranial nerve Any cranial nerve Ocular, bulbar Any cranial nerve Ataxia +/- +/- - -/+ - - NCS Mild +/- + Characteristic finding not present in our case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

INVESTIGATIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

USG NECK & THYRAID; ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

MRI report ,[object Object],[object Object]

NEUROLOGY OPINION : ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

ENT OPINION: ,[object Object],[object Object],[object Object],[object Object]

OPHTHALMOLOGIST OPINION ,[object Object],RIGHT LEFT EYE LIDS NORMAL NORMAL EYE LASHES NORMAL NORMAL CONJUCTIVA NORMAL NORMAL CORNEA CLEAR , SENSATION INTACT CLEAR, SENSATION INTACT IRIS COLOUR, PATTERN -NORMAL COLOUR, PATTERN -NORMAL PUPIL PUPIL 3mm, REACTING TO LIGHT PUPIL 3mm, REACTING TO LIGHT ANT CHAMBER NORMAL DEPTH NORMAL DEPTH LENS MINIMAL CHANGES MINIMAL CHANGES RETINOSCOPY +1.5/+1 +.5/+.5 EOM ABDUCTION  RESTRICTED DEXTRO ELEVATION, DEXTRO DEPRESSION  RESTRICTED LEVO ELEVATION, DEPRESSION  NORMAL EOM – FULL

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

NCS RIGHT PERONEAL NERVE RIGHT MEDIAN NERVE Conduction velocity 34.08m/s >51 Prox CMAP Amplitude 1.0mV N>4.4 Conduction velocity 54.92m/s >48 Prox CMAP Amplitude 8.7mV N>4.4

NCS report ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Course in the hospital ,[object Object],[object Object],[object Object],[object Object]

Patient now able to look right

NEUROLOGIST REVIEW ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

FINAL DIAGNOSIS ,[object Object],[object Object],[object Object]

Questions ,[object Object],[object Object],[object Object],[object Object]

CRITERIA FOR DIAGNOSING BBE ,[object Object],[object Object],[object Object],[object Object]

Miller Fisher Syndrome ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

GBS – The cranial nerve variants ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Bickerstaff brainstem encephalitis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Clinical profile of patients with BBE

Diagnostic Criteria for Guillain-Barrý Syndrome (Ashbury et al) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

REFRENCES ,[object Object],[object Object],[object Object],[object Object]

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Follow up ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Picture of the patient Ophthalmoparesis  complete/partial Symmetrical proximal weakness Facial weakness Ataxia

A Case of GBS - Lower Cranial Nerve Variant

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A Case of GBS - Lower Cranial Nerve Variant