CASE REPORT OF NEUROMUSCULAR

Presentan : Isnaini Ashar

Moderator : dr. Indra sari Kusuma H., Sp.S., Ph.D
Examiner : Prof.Dr.dr. Samekto W., P.FarK, Sp.FK(K),Sp.S(K)
dr. Astuti, Sp.S(K)
Time : Thursday, 16th November 2017
IDENTITY
▫ Name : Mr. R ▫ Occupation : Farmer
▫ Age : 39 yo ▫ Education : Middle
▫ Sex : Male school
▫ Date of admission : 20th
▫ Religion : Moslem august 2017
▫ Address : Tirtomulyo, ▫ Medical Record :
Bantul 01.82.xx.xx
Chief complaint:

Patient referred from PS Hospital with respiratory failure

from suspected Guillain Barre Syndrome
History of Present Illness

12 days before admission

• Patient complained fever and cold, but did not visit doctor.

10 days before admission

• Cold fever persisted  visited community health care and got
medical treatment (no information about the drugs).
6 days before admission
• The cold was getting better
• Fever persisted, improved after
taking the medicine but relapsed
• Tingling at the tips of fingers and
toes.
• Then the patient went to community
health care and hospitalized
5 days before admission
• Tingling sensation of the
fingers and toes spread up
slowly accompanied by
weakness in the fourth of
extremities, and assisted
when he was walking.
• The fever persisted.
4 days before admission
• The weakness in four extremities was getting worse, the patient could not
lift his both hands and feet, but still could be shifted.
• Patients was referred to PS hospitals
3 days before admission
• The weakness in four extremities was getting worse, he could not move his
legs and arms, followed by shortness of breathing.
• Then he was transferred to the ICU room and used mechanical ventilation
• The patient was diagnosed GBS.
The day on admission

•The patient still use mechanical ventilation, and

unconscious.
•The fever still persisted
•Then he was referred to Sardjito Hospital.
 • Denied history of similar illness, trauma, contact
History with chemical substances , weight loss, night
Of sweating, blood cough, chronic cough, and diarrhea
Previous • Denied of recent vaccination
Ilness • Denied history of hypertension, diabetes mellitus,
stroke and heart disease

History
of
Family • Denied history of similar illness
Illness
 Systemic Evaluation :
• Cerebrospinal : • Cardiovascular
Ascendence tingling at • Urogenital
the tips of fingers and • Gastrointestinal
toes, acute progressive • Musculosceletal
weakness at four
• Integument
extremities
• Respiratory : Dyspneu,
history of cold fever
Summary of Anamnesis
• A male, 39 years old, was referred from PS Hospital with
respiratory failure on patients suspected with GBS,
preceded by upper respiration tract infection, followed
by ascendens tingling at the tips of the fingers and toes
and acute progressive weakness in the four extremities .
The disease was developed into respiratory failure.
 Temporary Diagnosis
Clinical • Tingling at the tips of fingers and toes
ascendering, weakness at four extremities with
diagnosis acute onset progressively, dyspneu

Topical •DD : ● Radix and peripheral nerves

diagnosis •Medulla Spinalis

Etiological • DD : ● Autoimmune (Guillain Barre Syndrome)

diagnosis • Myelitis
Physical examination (August 21st, 2017)
Condition : weak
Mental status : not valid to be assess
Compos mentis (GCS): E4 VT M6) 1 1 1
1 1 1
Vital sign (BP, HR, T) : within normal limit 0 0
Respiration : mechanical ventilation 0 0
Cranial nerve : within normal limit
Meningeal sign (-) 1 1
Gloves and stocking paresthesia 0 0
Tetraparesis, muscle strength : 1 at four extremities 1 1
Urinary on DC 0 0 1
1

0 = areflex
 Support Examination
Laboratory
• Routine blood : leukocytosis (19.11x103/uL)
• Routine urine : within normal limit
• Liver function : abnormal (SGOT: 99 U/L ; SGPT: 123U/L)
• Kidney function : abnormal (BUN: 46 mg/dL; Cr: 1.73 mg/dL)
• Electrolyte : within normal limit
• Glucose : within normal limit
Thorax rontgen ECG

1. Pneumonia dextra
2. Endotracheal tube placement
with distal tube projected on Normal sinus rhythm, HR 90x/m
fourth thoracic vertebrae
 ENMG (22-8-2017)

MCS right and left tibialis nerve:

- longer distal latency, very low amplitude, slow nerve conduction velocity
H reflex right and left soleus muscle : no H wave

Severe polyradiculoneuropathy, support

Guillain Barre Syndrome AMAN/AMSAN type
Consultation
Anesthesia Department
(20/8/2017)
• Assessment : Suspected GBS
• Management : ▫ Hospital acquired pneumonia
▫ Mechanical ventilation
▫ Head up 300
▫ Inj. Omeprazol 40 mg/24 h
▫ Inj. Ceftriaxon 1 gr/12 h
Internist Department
(6/9/2017)
• Assessment :
▫ Mild Hipokalaemia
• Management :
▫ Inj. Cefepime 2g/8 h
▫ Nebulizer atrovent 2 cc/ 8 h
▫ Kalium 2x300mg
 Final Diagnosis
Clinical
• Guillain Barre Syndrome
diagnosis
Topical
• Radix and peripheral nerves
diagnosis
Etiological
• Auto-immune
diagnosis
Other • Hospital Acquired Pneumonia
diagnosis • Mild Hypokalaemia
Management
• Non Pharmacological therapy
▫ Patient and family education on therapy and
prognosis
▫ Physiotherapy
• Pharmacological therapy
▫ IVFD NaCl 0,9 % 20 dpm
▫ Methycobalamin 1.000 mcg/ 12 h IV
▫ Plasmapharesis 6 times
 Follow up

ENMG performed Consulted to

Tracheostomy Passive
Aff ventilator internist
procedure Physiotherapy
Mecobalamin Move
1000mg/12 h IV to ward Ceftriaxon stop
Plasma Plasma Plasma Cefepime 2g/8h IV
Ceftiaxon 1g/12 h IV exchange I exchange II exchange VI Kalium 300mg/12 h
admission
Hospital

Guillaine Barre Syndrome

Day 2 Day 4 Day 6 Day 14 Day 16 Day 17

Tetraparesis, muscle strength : 1 Tetraparesis, muscle strength : 2

HAP
Mild hypokalaemia
 Mecobalamin
3x500mg
Levofloxacin
1x500mg
Out
Active Decanulation Discharged patient
Home care
physiotherapy tracheostomy planing

Home
25/9/2017 13/10/
2017
Day 26 Day 30 Day 33 Day 35
Muscle strength : 5,
Tetraparesis, muscle strength : 3 Tetraparesis, muscle strength : 4 distal paresthesia

Mecobalamin 3x500mg
PROGNOSIS
• Death : ad bonam
• Disease : ad bonam
• Disability : ad bonam
• Discomfort : ad bonam
• Dissatisfaction : ad bonam
• Distitution : ad bonam
THANK YOU
Follow Up
Date 21/8/2017 23/8/2017 25/8/2017 3/9/ 2017

Complaint Weakness four extremities Weakness four extremities Weakness four extremities Weakness four extremities

Gen. Cond Weak, CM, E4VTM6 Weak, CM,, E4VTM6 Weak, CM,, E4VTM6 Weak, CM,, E4VTM6

1 1 1 1 2 2 2 2
Strength
1 1 1 1 2 2 2 2
- Respiratory failure
- Respiratory failure
-Weakness extremities
-Weakness extremities - Respiratory failure -Weakness extremities
- Acute kidney injury
Problem - Increase of transaminase -Weakness extremities -Respiratory improvement
-Increase of transaminase
enzyme - Pneumonia -Pneumonia
enzyme
- Pneumonia
- Pneumonia
- Consulted to Plasma - Plasma exchange I - Plasma exchange II -Plasma exchange VI
Planing
exchange - Tracheosthomy - Physiotherapy -Aff ventilator
- Infus NaCl 0,9% 16 - Infus NaCl 0,9% 16 - Infus NaCl 0,9% 16 Infus NaCl 0,9% 16
drop/mnt drop/mnt drop/mnt drop/mnt- Inj
- Inj Mecobalamin - Inj Mecobalamin - Inj Mecobalamin Mecobalamin 1000mg/12 h
Therapy
1000mg/12 h 1000mg/12 h 1000mg/12 h - Inj Ceftriaxon 1 gr/12 h
- Inj Ceftriaxon 1 gr/12 h - Inj Ceftriaxon 1 gr/12 h - Inj Ceftriaxon 1 gr/12 h
-Curcuma 3x1 tab - Curcuma 3x1 tab
 Date 5/9/2017 6/9/2017 15/9/2017 19/9/ 2017
Weakness four Weakness four
Weakness four Weakness four
Complaint extremities extremities
extremities, cough extremities
improvement improvement
Gene.
Weak, CM, E4VTM6 Weak, CM, E4VTM6 Weak, CM, E4VTM6 Weak, CM, E4VTM6
Cond
2 2 2 2 3 3 3 3
Strength
2 2 2 2 3 3 3 3
-Weakness extremities -Weakness extremities
-Weakness extremities
Problem -Pneumonia - HAP -Weakness extremities
-HAP
- Hypokalaemia
- Consulted to internist Decanulation (aff
Planing - Move to ward - Physiotherapy active
departement tracheostomy)
- Infus NaCl 0,9% 16 - Infus NaCl 0,9% 16 - Infus NaCl 0,9% 16 - Infus NaCl 0,9% 16
drop/mnt drop/mnt drop/mnt drop/mnt
- Inj Mecobalamin - Inj Mecobalamin - Inj Mecobalamin -- Inj Mecobalamin
Therapy 1000mg/12 h 1000mg/12 h 1000mg/12 h 1000mg/12 h
- Inj Ceftriaxon 1 gr/12 h - Inj. Cefepime 2g/8 h - Inj. Cefepime 2g/8 h - Inj. Cefepime 2g/8h
- Nebulizer atrovent 2 - Nebulizer atrovent 2
cc/ 8 h cc/ 8 h
- Kalium 2x300mg
 Date 21/9/2017 25/9/2017 13/10/2017 (out patient)
Weakness four extremities
Weakness four extremities Weakness four extremities
Complaint improvement, tingling at
improvement improvement
distal fingers
General Moderate, CM, Moderate, CM, Good, CM,
Condition E4V5M6 E4V5M6 E4VTM6
3 3 4 4 4+/5/5 5/5/4+
Strength
4 4 4 4 5/5/5 5/5/5
-Weakness extremities
Problem - -

Planing Discharge planing Home care

- Infus NaCl 0,9% 16 - Mecobalamin 3x500mg - Mecobalamin 3x500mg
drop/mnt - Levofloxacin 1x500mg
Therapy - Inj Mecobalamin
1000mg/12 h
- Inj. Cefepime 2g/8h
 20-8-2017 Routine blood 23-8-2017

AL 19,11x103/uL AL 14,11x103/uL
HB 15,4 g/dl HB 15,1 g/dl
AT 309 x103/uL AT 310 x103/uL
AE 5,56 x106/uL AE 5,45 x106/uL
Hematokrit 49,2 Hematokrit 47,0
Neutrofil 80,2% Neutrofil 87,9%
Limfosit 11,6% Limfosit 7,0%
Monosit 7,0 % Monosit 5,0 %
Eosinofil 0,3 % Eosinofil 0,0 %
Basofil 0,9 % Basofil 0,1 %
GDS 173 mg/dL KED 73 mm/1 h
BUN 46,0 mg/dl BUN 32,0 mg/dl
Creatinin 1,73 mg/dL Creatinin 0,67 mg/dL
Albumin 3,26 mg/dL Albumin 3,26 mg/dL
SGOT 99 U/L SGOT 28 U/L
SGPT 132 U/L SGPT 75 U/L
Na 138 mmol/l Na 135 mmol/l
K 5,00 mmol/l K 4,37 mmol/l
Cl 102 mmol/l Cl 100 mmol/l
 Urine examination 20-8-2017
Glukosa Negatif Eritrosit 38 /μL
Protein 1+ Leukosit 4 /μL
Bilirubin Negatif Sel Epithel 3.4 /μL
Urobilinogen Normal Silinder 0.3 /μL
pH 6.5 Bacteria 1.5 /μL
Berat Jenis >1.020 Kristal 0.0 /μL
Blood / Darah 1+ Yeast Like Cell 0.0 /μL
Keton Negatif Small Round Cell 0.0 /μL
Nitrit Negatif Silender Patologis 0.0 /μL
Lekosit Esterase Negatif Mucus 0.3 /μL
Warna Yellow Sperma 0.0 /μL
Konductivitas 12,3 mS/cm
 5-9-2017 Routine blood 15-9-2017
AL 10,9x103/uL AL 7,41x103/uL
HB 12,4 g/dl HB 12,9 g/dl
AT 185 x103/uL AT 274 x103/uL
AE 4,26 x106/uL AE 4,65 x106/uL
Hematokrit 35,9 % Hematokrit 44,4%
Neutrofil 89,7% Neutrofil 73,9%
Limfosit 7,2% Limfosit 19,4%
Monosit 2,3 % Monosit 5,5 %
Eosinofil 0,6 % Eosinofil 0,8 %
Basofil 0,2 %8,0 mg/dl Basofil 0,4 %
BUN 8,3 mg/dL Na 141 mmol/l
Creatinin 0,38 mg/dL K 4,06 mmol/l
Albumin 3,18 /dL Cl 102 mmol/l
Na 138 mmol/l
K 3,39 mmol/l
Cl 101 mmol/l
 20-8-2017 Blood gas analysis 4-9-2017
pH 7.44 pH 7.45
pCO2 40.6 mmHg pCO2 35.0 mmHg
pO2 93.0 mmHg pO2 170 mmHg
SO2 96.6 % SO2 99.5 %
HCO3 27.2 mmol/L HCO3 25.6
BE 3.3 BE 2.2
Culture of sputum (28-8-2017)
Organism : Enterobacter aerogenesis
Antibiotics Antibiotics
Ampicilin R Imipenem S
Azitromicin S Meropenem S
Gentamicin S Tetracycline S
Amikacin S Sulfamethoxazol S
Cefuroxim R Chloramphenicol S
Cefepime S Ofloxacin S
Cefotaxim S Cefotaxime S
Ciprofloxacin S Ceftazidime S
Fosfomicin S Ampicilin sulbactam R