Fulminant Guillain-Barre Syndrome Misdiagnosed as Spinal Cord Contusion After Motor Vehicle Collision

摘要

To the Editor: The acute development of neurologic deficit with sensory level after vehicular trauma is usually due to spinal cord injury, but possibilities for misdiagnosis exist. A 37-year-old woman was involved in high-speed motor vehicle collision as a driver. She suffered grade 3 concussion with very brief loss of consciousness. She reached emergency department within 45 minutes with complaints of chest and abdomen pain. The patient was well and healthy before the accident. She underwent primary and secondary survey that diagnosed lung contusion on the right. Plain x-ray of cervical spine, chest x-ray, and chest and abdomen computed tomography did not detect trauma of the spine. Within hours, the patient developed weakness, paresthesia, and numbness of the feet. Neurology assessment about 8 hours after the trauma established severe weakness and areflexia in the lower limbs, loss of vibration sensation to the level of the knees; touch sensation was diminished in the legs with a questionable level at 9-10 thoracic segment. "Spinal cord injury without radiological abnormality" was suggested; the ascending pattern of neurological deficit was ignored as possibly unreliable. High-dose cor-ticosteroid was prescribed, and an magnetic resonanse imaging was requested. However, over the next 12 hours, the patient developed flaccid lower paraplegia, upper parapa-resis, bilateral facial nerve palsy, and breathing difficulties. Cerebrospinal fluid study yielded increased protein of 1.2 gm/L with normal cell count. Fulminant Guillain-Barre syndrome (GBS) was diagnosed, confirmed by nerve conduction studies on the third day that revealed borderline velocities but very severe conduction block and absent late responses. At follow-up, full-blown demy-elinating features were confirmed: prolonged distal latencies, low velocities and amplitudes, prominent conduction block, absent sensory responses, delayed direct, and reflex facial nerve responses. Unfortunately, prominent denervation was also found. The patient was mechanically ventilated. She received repeated courses of intravenous imrnunoglo-buline, but the course of disease was protracted and severe, and she finally remained wheelchair bound.