Localization: diffuse sensory and motor neuropathy, probably concomitant polyradiculopathy and sensory ganglionopathy.

The presence of diffuse areflexia is suggestive for either a primarily demyelinating neuropathy and/or presence of poyradiculopathy. The occurrence of severe neuropathy after a vaccination implies post vaccination Guillain Barre syndrome (GBS). However, there are atypical features: although sensory symptoms and neuropathic/ radicular pain are common features of GBS ¹, severe loss of proprioception is considered an atypical feature.  A concomitant sensory ganglionopathy is a possibility given the severe multi-modality sensory loss. Furthermore, the course of the weakness was also not typical for GBS as nadir of weakness is usually reached in 4 weeks in 90% of patients. Other differential diagnosis include axonal variant of GBS (acute sensorimotor axonal neuropathy; AMSAN ), acute onset chronic inflammatory demyelinating polyneuropathy (A-CIDP),  toxins /drugs (arsenic, thalium, disulfiram, oxaliplatin, taxol, suramin, nitrofurantoin, podophyllin), peripheral nerve vasculitis (polyarthritis nodosa, churg-strauss, rheumatoid arthritis, Sjögren’s syndrome), porphyria, Lyme disease, sarcoidosis, amyloidosis, neurolymphomatosis and paraneoplastic neuropathy. If the patient is immunocompromised, opportunistic infections such as cytomegalovirus are to be excluded. EMG study can narrow the differential down by showing segmental demyelination. Click here for EMG and nerve conduction study.

CSF : Normal cells, Glucose 55mg/dl, total protein: 171mg/dl, ACE: WNL. albumin: 73.1mg/dl (0.0-35.00), IgG: 14.2mg/dl (0.0-5.4), IgG/Alb ratio 0.19 (<0.28), No oligoclonal bands.   CSF  culture and serological studies negative. MRI brain W/WO:  mild small vessel disease, MRI of C/T/L spine: negative for compressive myelopathy or signal abnormality in the spinal cord.CXR: right middle lobe infiltrate suggestive for pneumonia

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Reference

1.         Dimachkie MM, Barohn RJ. Guillain-Barre syndrome and variants. Neurologic clinics 2013;31(2):491-510.