Flaccid Paralysis, Acute

Key Features

• Can occur as a result of a lesion anywhere along the neuroaxis; the key to diagnosis is localizing the lesion

• Associated changes in reflexes, sensory changes, abnormal reflexes such as a positive Babinski sign, and bowel and bladder changes can help in localizing the lesion

• Common causes

  • Mass lesions

  • Infectious; postinfectious

  • Toxins (eg, from a tick or due to botulism)

  • Metabolic

Clinical Findings

• Features assisting diagnosis are age, a history of preceding illness, rapidity of progression, cranial nerve findings, bowel and bladder changes, and sensory findings

• Increased reflexes and upgoing toes suggests a CNS lesion

• Fatigability in sucking on a bottle and constipation may be seen in infants with botulism

• Ascending paresthesia and loss of reflexes before development of overt weakness may be present in patients with Guillain-Barre syndrome (also known as acute inflammatory demyelinating polyneuropathy [AIDP])

• Ophthalmoplegia, ataxia, and loss of reflexes is classic constellation of symptoms in patients with the Miller Fisher variant of Guillain-Barre syndrome

• Back pain is suggestive of a spinal cord lesion, such as in transverse myelitis or a spinal cord mass

Diagnosis

• MRI

  • Helpful when a spinal cord or brain lesion is suspected

  • Essential when mass lesion is suspected

• Once a mass lesion is excluded, cerebrospinal fluid (CSF) studies, including opening pressure, can be obtained

• Viral cultures (CSF, throat, and stool) and titers aid in diagnosing poliomyelitis

• A high sedimentation rate may suggest tumor, abscess, or autoimmune disorder

• EMG and nerve conduction studies (NCSs)

  • Can be helpful in diagnosing Guillain-Barre syndrome

  • Fibrillation potentials and increased compound muscle action potential amplitudes with high-frequency stimulation suggest botulism

Treatment

• Remove ticks

• Administration of botulism immune globulin administration shortens hospital stay

• IVIg or plasmapheresis for patients with Guillain-Barre syndrome shortens hospital stay

• Corticosteroids, IVIg, and plasmapheresis have been used in transverse myelitis

• Supportive treatment

  • Pulmonary toilet

  • Adequate fluids and nutrition

  • Bladder and bowel care

  • Prevention of pressure ulcers

  • Psychiatric support