Practical approach to the patient with acute neuromuscular weakness

Table 1 Differential diagnosis of acute neuromuscular paralysis

Anterior horn cell disorders

Poliomyelitis

West Nile virus

Peripheral neuropathy/polyradiculopathy

GBS

Porphyria

Diptheria

CMV polyradiculopathy

Lyme neuroborreliosis

Toxins (heavy metals, e.g., arsenic, mercury, hexacarbon, drug intoxication, organophosphate, Buckthorn)

Critical illness polyneuropathy

Tick paralysis

Vasculitic neuropathy

Neuromuscular junction disorder

MG

Lambert-Eaton syndrome

Neuroparalytic envenomation (e.g., tick and snake bites)

Botulism

Organophosphate and carbamate

Hypermagnesemia

Prolonged neuromuscular blockade

Overdose of anticholinesterases

Muscle disease

Periodic paralysis (hypokalemic: Hereditary and secondary, hyperkalemic)

Hypophosphatemia

Critical illness myopathy

Polymyositis, dermatomyositis, infectious myositis (e.g., dengue myositis)

Acute rhabdomyolysis

Adapted from Maramattom et al[2]. GBS: Guillain-Barré syndrome; CMV: Cytomegalovirus; MG: Myasthenia gravis.

Table 2 Diagnostic criteria for Guillain-Barré syndrome

Features required for diagnosis

Progressive weakness in both arms and legs

Areflexia or hyporeflexia

Features that strongly support the diagnosis

Progressive motor weakness up to 4 wk

Relative symmetry of symptoms

Mild sensory involvement

Cranial nerve involvement, especially bilateral facial

Weakness

Autonomic dysfunction

Pain

Albuminocytological dissociation in CSF

Electrodiagnostic features of demyelination

Features that should raise doubt about the diagnosis

Respiratory failure with limited weakness of limbs at onset

Severe sensory signs at onset

Bladder or bowel dysfunction at onset and persistence of dysfunction in the disease course

Fever at onset

Sharp sensory level

Slow progression with limited weakness without

Respiratory involvement

Persistent asymmetry of motor weakness

Mono/polymorphonuclear leukocytosis in CSF

Adapted from Asbury et al[14]. CSF: Cerebrospinal fluid.

Table 3 Guillain-Barré syndrome Disability score[17]

0 Healthy state

1 Minor symptoms and capable of running

2 Able to walk 10 m or more without assistance but unable to run

3 Able to walk 10 m across an open space with help

4 Bedridden or chair bound

5 Requiring assisted ventilation for at least part of the day

6 Dead