A 60-year-old woman with a PMH significant for hypertension, hypothyroidism, and frontotemporal dementia presented to the emergency department with one day of unsteady gait and left-sided facial droop. Also, she was having new bilateral hip pain and low-back pain for the past week. She endorsed having a self-resolving diarrheal illness 2 weeks ago, and she had her annual flu shot one week prior. Her physical exam was significant for left-sided facial weakness involving both her upper and lower face, as well as left-sided lagopthalmos. Her extremity strength was 5/5 throughout, and her lower extremity reflexes were 2+. CBC, BMP, and LFTs were unremarkable. CT head without contrast was unremarkable.
Given her facial droop and risk factors, she was admitted to the hospital to evaluate for an acute stroke.
A: Sometimes it is difficult to be 100% sure if facial weakness is central vs. peripheral using only the physical exam. Nobody likes to miss a stroke, so many older patients with Bell’s palsy will have an MRI done just to be sure. The lagopthalmos strongly suggests against a central cause of facial droop. A stroke is extremely unlikely. This patient likely has Bell’s palsy. She was prescribed prednisone and valacyclovir. Glucocorticoids increase the odds of recovery, and anti-HSV medications may also help. Eye care is also important to prevent corneal injury. Artificial tears can be used when the patient is awake, and the affected eye can be taped shut during sleep.
The MRI scan was negative for acute stroke. On hospital day 1, the patient’s lower-back pain intensified, and she developed progressive bilateral leg weakness and areflexia of the bilateral knees and ankles.
A: New lower-back pain and leg weakness should have you worried about spinal cord compression, which can come from a variety of causes—malignancy, spinal epidural abscess, and more. Differential also includes demyelinating polyneuropathy such as Guillain Barré syndrome.
Emergent MRI of the lumbar spine with and without contrast should be your next step.
MRI of the lumbar spine was obtained and showed diffuse enhancement of all cauda equina nerve roots without nodularity.
A: Lumbar puncture.
Lumbar puncture was performed; CSF obtained was acellular but showed a protein level of 267 (normal range 15–45). The patient was diagnosed with Guillain Barré syndrome. She was given 5 days of IVIG.
