CASE 86: WEAKNESS OF THE LEGS
History
A 48-year-old man presents to the emergency department with weakness of his legs. Four
weeks earlier he had symptoms of an upper respiratory tract infection. Four days before
admission he had a feeling that there was something wrong in his feet, and 3 days before
admission he started to develop some difficulty in walking. Now he says that he is hardly
able to move his legs below his knees. Both feet have also become painful over the last day
or so. His bowels and bladder are functioning normally. He has no significant past medical
history. He neither smokes nor drinks alcohol and is taking no medication.
Examination
He looks well but is anxious. His pulse rate is 104/min, and blood pressure 162/98 mmHg.
His jugular venous pressure is not raised and examination of his heart, respiratory and
abdominal systems is normal. Neurological examination shows grade 1/5 power below his
knees and 2/5 power for hip flexion/extension. The tone in his legs is reduced. Knee and
ankle reflex jerks are absent. There is impaired pinprick sensation up to the thighs and
reduced joint position sense and vibration sense in the ankles. Neurological examination
of his arms is normal.
Initial haematology and biochemistry results are normal.
A lumbar puncture is performed with the following results:
NormalCerebrospinal fluid (CSF): clear
Pressure 170 mm CSF !200 mm CSF
CSF protein 3.4 g/L !0.4 g/L
CSF glucose 4 mmol/L #70 per cent
plasma glucose
Leucocytes 5/mL !5/mL
Plasma glucose 4.5 mmol/L 4.0–6.0 mmol/LGram stain: no organismsINVESTIGATIONS
Questions
- What is the diagnosis?
- What are the major differential diagnoses?
- How would you manage this patient?