Case: 45-year-old with Diabetes Mellitus

00:01 Now, let's talk about acute inflammatory demyelinating polyneuropathy.

00:07 Let's begin with a case.

00:09 This is a 45-year-old man with diabetes who presents with a two day history of weakness in the legs.

00:14 He reports a history of gastrointestinal illness about two weeks ago, that resolves spontaneously.

00:21 Two days ago, he began to notice heaviness in his feet, that has now spread to both legs and hands.

00:27 He has difficulty walking at home, even short distances, and he reports difficulty opening a jar this morning.

00:34 He reports mild paraesthesia in his legs bilaterally.

00:38 And his exam shows four out of five strength symmetrically in both legs, and four out of five grip in wrist extension strength.

00:45 Since your exam shows mildly reduced light touch in his legs to the mid calf, and he is diffusely a reflexive.

00:52 So what's your diagnosis? Well, there's a number of features of this case that I want you to key in on.

00:57 First is the distribution.

00:59 This is a symmetric and the length dependent ascending process.

01:03 It began in both legs, it spread up the legs and now is involving the hands.

01:08 And that distribution is consistent with a peripheral nerve disorder.

01:12 The second is the sensory exam.

01:14 There is sensory involvement, but it's relatively mild.

01:18 And it's much less and out of proportion than what we're seeing with the strength exam.

01:23 The third is the reflexes.

01:25 This patient is diffusely a reflexive and that points us to a peripheral nerve disorder.

01:30 And then the last key feature are two wild cards.

01:33 The first is that this is a rapid onset condition that has begun in an early subacute time course.

01:41 Symptoms began only days ago and have rapidly worsened.

01:44 And the second is this recent gastrointestinal illness, which is classic for this condition.

01:50 So what's the diagnosis? Is this HIV-associated polyneuropathy, acute inflammatory demyelinating polyneuropathy, diabetic polyneuropathy, or mononeuritis multiplex? Well, this doesn't sound like HIV associated polyneuropathy.

02:06 That's a chronic length-dependent peripheral polyneuropathy.

02:09 So it is length dependent.

02:10 It an progress up the lower extremity to the upper extremity, but this is a chronic onset condition.

02:17 Our patient is presenting with a severe acute and rapidly worsening process.

02:22 The patient also doesn't have other history to suggest this, but workup may be needed in selected cases.

02:28 This doesn't sound like diabetic polyneuropathy.

02:31 Again, that's a chronic onset length dependent process.

02:34 And that's not the time course for this illness.

02:36 Areflexia is also an often very uncommon in diabetic polyneuropathy.

02:41 This is not a mononeuritis multiplex.

02:44 Mononeuritis multiplex is multiple mononeuropathies.

02:47 So it's carpal tunnel syndrome and ulnar neuropathy or a peroneal neuropathy and a carpal tunnel.

02:53 And that's not what we have here.

02:54 Our patient is presenting with a diffuse symmetric polyneuropathy And this is a classic or typical presentation of someone with Guillain-Barré.

03:03 There's an antecedent GI illness now associated with a rapidly progressive ascending polyradiculoneuropathy with areflexia.