Quiz 7

A 24 year old patient was brought into the ER after having been seen by the prison doctor on two separate occasions where nothing wrong was found. He is a pleasant young man and hates to be in prison for the gas station robbery that he committed 2 years ago. He has complained about feeling weak. The prison doctor ran a bunch of tests on him that came out to be normal. These included a CT brain, Electrolytes, liver function tests and chest x-ray. His past medical history is significant for repeated diarrhea and upper respiratory infections that had been investigated in the past and his doctor had told him that he had an immunodeficiency that is supposed to be one of the commonest types of immunodeficiencies. He does not remember its name.
Physical exam now reveals a man who cannot move his limbs, has decreased tone and absent deep tendon reflexes. There are no other localizing signs and fundoscopy is normal. His cardiac exam reveals a few extrasystoles. Chest exam reveals no crackles or wheezing.

Q1. Which of the following is INCORRECT about this patient.

CSF findings in this are similar to those found in spinal canal stenosis (Froin's syndrome).

Repeat CT scan would most likely be normal

He should be have his vital capacity checked immediately.

Raised pCO2 is the best indicator for need to intubate

EMG with Nerve Conduction study is a useful test in this condition
The answer (false statement) is raised pCO2 is the best indicator for need to intubate. By this time it will be too late and there are high chances for respiratory arrest. Vital capacity is considered the best indicator to intubate.  The diagnosis here was got by most who answered - Guillian barre syndrome. The immunodeficiency that was described and mentioned to be one of the commonest is IgA deficiency. In this condition the most important fact to remember is that unless there is SEVERE infection, immunoglobulin concentrates and blood products containing IgA are contraindicated. If this is used, the risk of anaphylaxis is high.

Q2. Which of the following statements about the treatment of this patient's problem is FALSE ?

Concentrated immune globulin (IVIg) is contra-indicated

Plasmapheresis is the treatment of choice

Treatment has no impact on the long term neurological deficit

To intubate the patient, one should not wait until pCO2 is elevated

None of the above is false.

All the statements in Q2 are true.