An 80-year-old man was recovering from diarrhoea when he developed difficulty in swallowing and had a
choking fit while eating a sandwich.
He took to his bed, complained of back pain, bilateral leg pain, numbness in the feet and could not stand up.
He smoked 20 cigarettes a day and drank 20 units of alcohol each week. Past medical history included
bilateral hip replacements and osteoarthritis of both knees.
On examination he was confused with slurred speech. There was bilateral ptosis, ophthalmoplegia and mild
proximal weakness in both legs. All tendon reflexes were absent and the plantar responses were equivocal.
He did not co-operate with the examination of the sensory system. The bladder was palpable up to the level of
the umbilicus. The prostate was smoothly enlarged and the rectum was full of faeces.
What is the most likely diagnosis?
Brain stem infarction
Guillain-Barre syndrome (Correct)
Motor neurone disease
Myasthenia gravis
Transverse myelitis
Guillain-Barre syndrome, also known as acute post infective neuropathy, often follows one to three weeks after an infection. Campylobacter jejuni is a well recognised cause of severe GBS.
A brain stem infarct producing bilateral signs is not compatible with life.
Motor neurone disease has a more insidious presentation and does not affect the eye muscles. Myasthenia
gravis may present like this.
However, despite muscular weakness, deep tendon reflexes are often preserved and urinary incontinence and
diarrhoea may be a feature due to cholinergic crisis.
Transverse myelitis is inflammation of the spinal cord and does not produce brain stem signs.