Medical Emergencies · patient case question
What is the most likely explanation for the new symmetrical ascending weakness two weeks after his influenza vaccination?
Patient case: The tremor that came before the toothache
demo: 74-year-old male, brought by his daughter
chief: Broken lower molar and difficulty maintaining oral hygiene.
history: Parkinson disease diagnosed six years ago. He now lives with his daughter and rarely leaves the house; she manages his transport and his brushing. Two weeks ago he had his annual influenza vaccination, and since then she reports he has become noticeably weaker in both legs, though he has no fever.
meds: Carbidopa-levodopa. No anticoagulants.
findings: Masked facies with reduced blink rate. Pill-rolling tremor of the right hand at rest that settles when he reaches for an object. Generalised plaque accumulation and drooling. Symmetrical ascending weakness of the lower limbs with absent ankle reflexes.
Show answer and explanation
Correct answer: D. Guillain-Barre syndrome
- A. Parkinson disease causes rigidity and bradykinesia, not flaccid weakness with areflexia, and it does not deteriorate abruptly over two weeks in this pattern.
- B. Myasthenia gravis causes fatigable weakness that worsens through the day, characteristically affecting extraocular and bulbar muscles first with ptosis and diplopia, and it preserves reflexes.
- C. Amyotrophic lateral sclerosis is slowly progressive over months, is typically asymmetrical, and mixes upper motor neuron signs such as hyperreflexia and spasticity with lower motor neuron wasting and fasciculations. Its reflexes are usually brisk, not absent.
- D. Correct. Guillain-Barre syndrome is an acute inflammatory demyelinating polyradiculoneuropathy that follows an immunological trigger, classically Campylobacter infection but also vaccination, by one to three weeks. It gives symmetrical ascending weakness with loss of deep tendon reflexes and little or no fever. It is a medical emergency because it can ascend to the respiratory muscles.
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