P-PN020. Acute flaccid paralysis: Guillain-Barré Syndrome mimics

Abstract

Introduction . Guillain-Barré syndrome (GBS) is the commonest cause of acute flaccid paralysis. However, clinicians should not miss the other causes of acute flaccid paralysis which may mimic GBS. Results . We present 3 cases of flaccid areflexic paralysis which presented acute/subacutely resembling GBS. Case 1: A 29-year-old lady presented with 2-week history of bilateral lower limb weakness with left hip pain for 3 years. Investigations revealed hypercalcaemia, hypophosphataemia, elevated ALP, vitamin D deficiency, hyperparathyroidism with right parathyroid adenoma from parathyroid ultrasonography and scintigraphy. She had plasma exchange for presumed GBS, but her lower limb weakness worsened and progressed to involve upper limbs and facial muscles. Her weakness improved after parathyroidectomy and the diagnosis was revised to hyperparathyroidism-related polyneuropathy. Case 2: A 28-year- old lady with underlying epilepsy and intellectual disability presented with progressive weakness of extremities over 3 weeks after prolonged fasting. Her weakness did not improve after treatment with immunoglobulin for GBS. Investigations showed positive urine porphobilinogen and raised urine delta-aminolaevulinic acid. A diagnosis of acute intermittent porphyria was considered most likely and her weakness improved after continuous glucose loading. Case 3: A 52-year-old lady who had bariatric surgery presented with bilateral lower limb weakness over 4 weeks after recurrent bouts of vomiting and excessive weight loss. Investigations revealed vitamin D deficiency, hypoalbuminaemia, hyperhomocysteinemia, low folate and low normal serum thiamine. As her weakness continued to progress, a diagnosis of acute nutritional neuropathy was considered more likely. Her weakness improved following multivitamins replacement. All 3 patients had normal CSF analysis except Case 1 who showed cyto-albuminologic dissociation. Sensorimotor axonal polyneuropathy was the electrodiagnosis demonstrated in all the cases. Conclusion . Clinicians should have high index of suspicion when treating acute flaccid paralysis with progressive disease and null response to immunotherapy as the neurology is reversible with treatment of the underlying cause.