An interesting case

of quadriplegia
- Dr. K.SUBHASHINI
UNIT V
Dr. Ramesh Sir unit
 28 year old female came with chief complaints of
inability to move both the lower limbs and upper limbs for a
period of 6 hours.

History of presenting illness:

• Pt was apparently normal 6hrs before and then developed
weakness of both lower limbs and upper limbs sudden onset
• H/o difficulty in combing hair, lifting hand above head
• H/o difficulty in mixing food, buttoning shirt, writing
• H/o difficluty in standing, climbing stairs present
• H/o difficulty in holding slippers present
• No H/o difficulty to lift head from bed
• No history sugg of sensory loss
• No history sugg of Cranial nerves involvement
• I : H/o loss of sense of smell / altered
• II : H/o disturbance of vision
• III, IV, VI : H/o double vision
• V : H/o sensory loss over face, chewing disturbances
• VII : H/o loss of taste, salivation, angle deviation, drooling of saliva
from mouth
• VIII : H/o hearing loss, vertigo, tinnitus
• IX, X : H/o nasal regurgitation, nasal twang, difficulty in swallowing,
hoarseness of voice
• XII : H/o difficulty in moving tongue
• No H/O involuntary movements
• No H/O Loss of consciousness
• No H/O bladder and bowel disturbances

• No H/O trauma/neck pain

• No H/o nausea / vomiting / loose stools
• No H/o fever
Past H/O :

• Pt had similar illnesses 2 episodes- 1st episode 2 yrs back

And second episode 1 year back for which no triggers were found
Pt was treated at nearby hospital and weakness recovered
completely .
• No h/o DM/SHTN/ TB/ bronchial asthma/ CAD/ CKD
Personal h/o:
Regular menstrual cycles 5/30
LMP 20 days back
Normal bladder and bowel habits
Mixed diet

Family h/o : no similar illnesses in family

 SUMMARY
28 year old female presented with complaints of weakness of
both the lower limbs and upper limbs for past 6 hours .
Similar episodes in the past 2 years with no triggers found and
treated at nearby hospital
 GENERAL
EXAMINATION
• CONSCIOUS
• ORIENTED
• COMFORTABLE AT REST
• MODERATELY BUILT AND NOURISHED
• AFEBRILE
• NO PALLOR/CYANOSIS/CLUBBING/PEDAL EDEMA/ICTERUS
• NO LYMPHADENOPATHY
• NO NEUROCUTANEOUS MARKERS
• NO NERVE THICKENING

VITALS
BP-120/80 mmhg
PR -88/min , normal volume , regular rhythm , no specific character , no radio
radial & radiofemoral delay
RR- 15/min , thoracoabdominal , single breath count : > 20
SPO2 -98 % in room air
HIGHER MENTAL FUNCTION:

• Right handed individual

• Conscious; oriented to time ,place and person
• Speech normal
• Language normal
• Memory intact
• Intelligence normal
• Attention- intact
• Mood and emotions- Normal
• MMSE -30
 CRANIAL NERVE EXAMINATION

OLFACTORY NERVE – Able to perceive and identify smell

in both the nostrils
OPTIC NERVE

RIGHT LLEFT
VISUAL ACUITY
Distant vision 6/6 6/6

FIELD OF VISION NORMAL NORMAL

COLOUR VISION NORMAL NORMAL
FUNDUS NORMAL NORMAL
OCCULOMOTOR/TROCHLEAR &ABDUCENT
NERVE RIGHT LEFT
EXTRA OCULAR MOVEMENTS Normal Normal
PUPIL 3mm, Reacting to 3mm, Reacting to
light light
NYSTAGMUS - -
SACCADES& PURSUITS Normal Normal
VERGENCE Intact Intact
FIXATION Intact Intact
Eyelids Normal Normal
Direct light reflex Present Present
Indirect light reflex Present Present
NEAR REFLEX Present Present

RIGHT LEFT
TRIGEMINAL NERVE Jaw jerk Present
Corneal reflex Present Present
Sensation over face – intact Cojunctival Present Present
reflex
MUSCLES OF NORMAL NORMAL
MASTICATION
FACIAL NERVE

• Wrinkling +
• Able to raise eyebrows
• Able to close eyes tightly
• Nasolabial fold – not obliterated
• Able to blow out cheeks
• Able to whistle
• No Deviation of angle of mouth
• Taste sensation over anterior 2/3rd of tongue- intact

VESTIBULO COCHLEAR NERVE

RINNIES TEST : Bilateral AC > BC

Weber’s : no lateralization
GLOSSOPHARYNGEAL AND VAGUS NERVE
• Palatal arch - moves symmetrical
• Uvula in midline
• Gag reflex- present

SPINAL ACCESSORY NERVE

• Trapezius and sternocleidomastoid muscle – intact on both sides

HYPOGLOSSAL NERVE
• Able to protrude tongue
• Able to roll the tongue from side to side
• Able to form bolus of food
• No deviation on protrusion
• No fibrillations
 MOTOR SYSTEM
BULK
RIGHT LEFT
ARM 26.5 26.5
UPPER LIMB FOREARM 24 24
THIGH 43 43
LOWER LIMB CALF 33 33

TONE
RIGHT LEFT
Hypotonia
UPPER LIMB Hypotonia

LOWER LIMB HYPOTONIA HYPOTONIA

 POWER
RIGHT LEFT

FLEXION
EXTENSION
UPPER LIMB ABDUCTION
SHOULDER ADDUCTION 0/5 0/5
JOINT EXTERNAL ROTATION
INTERNAL ROTATION

FLEXION
EXTENSION
ELBOW JOINT SUPINATION 0/5 0/5
PRONATION

FLEXION
WRIST JOINT EXTENSION 0/5 0/5

HAND MUSCLES 0/5 0/5

• NECK

NECK POWER

FLEXION 5/5

EXTENSION 5/5
Lower limbs
RIGHT LEFT

0/5
ABDUCTION 0/5
ADDUCTION
FLEXION
EXTENSION
HIP JOINT
INTERNAL
ROTATION
EXTERNAL
ROTATION

0/5
FLEXION 0/5
KNEE EXTENSION

PLANTAR FLEXION 0/5 0/5

DORSIFLEXION
ANKLE INVERSION
EVERSION
 SUPERFICIAL
REFLEXES
RIGHT LEFT
CORNEAL Present Present
CONJUNCTIVAL Present Present
ABDOMINAL Absent Absent
PLANTAR Flexor Flexor
 DEEP TENDON
REFLEXES
RIGHT LEFT
JAW JERK Present
BICEPS Absent Absent
TRICEPS Absent Absent

SUPINATOR Absent Absent

FINGER Absent Absent

FLEXION
KNEE absent absent

ANKLE Absent Absent

• COORDINATION TEST – could not be assessed

• GAIT : NOT ASSESSED

• SENSORY SYSTEM

RIGHT LEFT
TOUCH Intact Intact
PAIN Intact Intact
TEMPERATURE Intact Intact
VIBRATION Intact Intact

JOINT SENSE Intact Intact

ROMBERGS Not assessed

CORTICAL SENSATION-
Two-point discrimination, stereognosis , graphesthesia –
INTACT
LHERMITTE SIGN - NEGATIVE
Autonomic nervous system examination- normal
No signs of meningeal irritation

Examination of spine and cranium -

No deformity/ spine tenderness/ gibbus
OTHER SYSTEM EXAMINATION:
CVS -S1S2 + no murmur
RS - BAE+ no added sound

P/A - soft no organomegaly

 SUMMARY
28 year old female has come with history of neurological deficit in
the form of sudden onset weakness of both lower limbs and upper
limbs of duration 6 hours
 with similar episodes over a period of 2 years with complete
recovery after treatment
 hypotonia
 power 0/5 in both lower limbs and upper limbs
 absent DTR in lower limbs and upper limbs .
 No sensory deficits
 No bulbar / ocular involvement

Acute flaccid paralysis

 INVESTIGATIONS
• CBC – normal
• SODIUM 140
LFT RFT normal
• Serum electrolytes POTASSIUM 2.0 (LOW)

• S.calcium -9.5 mg/dL

• S.Magnesium 2.1 mg /dL
• Serum lipid profile- normal
• Free thyroid profile – within normal limits
• Renal ultrasound revealed normal sized kidneys with
preserved cortical thickness and corticomedullary distinction.
• DIAGNOSIS : HYPOKALEMIC PARALYSIS

Treatment : KCl infusion – around 80mEq was given

Approach to hypokalemia
Hypokalemia evaluation
SERUM POTASSIUM < 3.5
mmol/L

1.ARTIFACT-
PHLEBOTOMY
2.ACUTE
STEP 1 :Rule out LEUKEMIA-
LEUKOCYTES
PSEUDOHYPOKALEMIA TAKE UP
POTASSIUM
 STEP 2 : CHECK FOR
TRANSCELLULAR SHIFTS

• Insulin

• Increased β2-adrenergic sympathetic activity: post–

myocardial infarction, head injury, theophylline

• β2-Adrenergic agonists: bronchodilators, tocolytics

• Drugs like chloroquine

• Thyrotoxic periodic paralysis

 STEP 3 : URINE K+
 >15mmol/g Cr – renal loss
 < 15 mmol/g Cr – extrarenal loss

300 mmol /g Cr loss  renal loss

 Step 4 : TTKG
>4  DISTAL K+ secretion
<2  increased tubular flow ( osmotic diuresis)

TTKG – 4.8  DISTAL K+

SECRETION
 STEP 5 : BLOOD
PRESSURE

LOW OR
NORMAL
HIGH

ABG
 ABG
pH 7.33
pCO2 27 mm Hg
pO2 98 mm Hg
Na+ 135 mEq/L
K+ 2.3 mEq/L
HCO3- 14.2 mEq/L
BE -11.7 mmol/L
Cl- 112 mEq/L

NORMAL ANION GAP METABOLIC ACIDOSIS

 ABG

METABOLIC METABOLIC
ACIDOSIS ALKALOSIS

URINE CHLORIDE

Cl- >20 Cl- <10

 PROXIMAL RTA
 DISTAL RTA Urine
 DKA Ca/Cr
 AMPHOTERICIN B • Vomiting
 ACETAZOLAMIDE <0.15 • Chloride
>0.20 • Thiazide diarrhea
• Loop
diuretic
diuretics • Gietelman’s
• Bartter’s
syndrome
syndrome
Proximal vs Distal RTA
• Urine pH – 7.01

• Urine Calcium /creatinine ratio - increased

0.3 ( normal <0.20)
 DISTAL RTA

Defect in the H+-K+-ATPase that impairs H+ secretion and K+

reabsorption  systemic acidosis 
diminish net proximal fluid reabsorption volume contraction
and activation of the renin-aldosterone system increased renal
K+ secretion.
Defects in the basolateral anion exchanger (AE1) also can cause distal RTA.
In this case, the lack of basolateral HCO3 − exit leads to intracellular
alkalinization, which inhibits apical proton secretion.
Causes of distal RTA
• Serological investigations
 anti-Sjögren’s syndrome related antigen A (SS-A)
 anti-Sjögren’s syndrome related antigen B (SS-B) antibodies
were positive

HYPOKALEMIC PARALYSIS
DISTAL RENAL TUBULAR ACIDOSIS
Secondary to autoimmune disorder ( Sjogrens)