Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.
I'm Pradip Kamat and I'm Rahul Damania. We are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine.
Welcome to our episode, A Three-Year-Old with recent cough and leg weakness.
Here's the case presented by Rahul.
A 3-year-old previously healthy female presented to the hospital with a 2-week history of productive cough and congestion and the new 1-day onset of bilateral weakness. Today, the mother noticed weakness and inability to stand/walk following after shower as well as her voice becoming hoarse. She also noticed her lying more limp sitting on her lap, unable to sit up fully without her mother supporting her. She had no trouble holding up her head. The mother endorses increased fussiness but is able to be consoled. Decreased p/o intake, last meal was yesterday. About 1-2 weeks prior to this patient also had non-bloody diarrhea that resolved spontaneously after a few days.
UOP normal with 2-3 wet diapers. No difficulty breathing. No history of head trauma or trauma to lower extremities, no erythema/swelling to joints. No pain associated with leg movement. No previous difficulty with walking - developing normally otherwise. No fever, recent travel, H/O sick contact at home (sibling with URI). No allergies, immunization UTD. CMP largely unremarkable. CBC with leukocytosis to 19.72 with L shift and platelets of 647. CRP 0.3, ESR 12.
Afebrile, RR 24/min, HR 130, BP 140/86.
On PE: Patient was coughing, had a hoarse voice heart and lung exam was normal. Normal abdominal exam. No rash
Neurological exam: PERRL, (A+O) X3, 3-4/5 strength at ankles and knees and 5/5 in arms, +UE DTR's but none at patella or ankles. Has a wide-based ataxic gait and needs to hold on to the wall/furniture to ambulate.
Rahul, to summarize key elements from this case, this patient has:
A cough with a hoarse voice
No fever
Inability to stand/walk (i.e. lower extremity weakness) with no DTRs in patellae or ankle
Normal mental status
Diarrhea (non-bloody) preceding neurological weakness
All of these bring up a concern for Guillain-Barré syndrome-An immune-mediated disease possibly triggered by a recent infection and targeting the peripheral nervous system.

Let's transition into some history and physical exam components of this case?
What are key history features in this 3-year-old child

Acute (B) leg weakness
Cough with hoarse
Diarrheal illness
No fever, no /o rash or trauma

Pradip, Are there some red-flag symptoms or physical exam components which you could highlight?

Bilateral lower leg weakness with absent patellar and AJ DTRs
Normal mental status
No rash, trauma
Rahul continues with our case, the patient's initial labs and imaging were consistent with:
The CMP, CBC with differential, and blood gas were unremarkable
ESR = 12, CRP 0.29, pro-cal 0.09(all normal)
Normal CPK
Normal Urine analysis
A lumbar puncture revealed colorless CSF with 4 white cells, 0 reds, Glucose 73 (serum Glucose 90) and protein 94, Gram stain and culture-negative
MRI of the brain and lumbar spine with and without contrast was completely normal
Chest radiograph with no infiltrate or atelectasis
Nerve conduction studies were not performed

Any patient with acute ascending lower extremity flaccid paralysis with CSF showing acellular protein predominance should be considered to have Guillain-Barré syndrome unless proven otherwise. MRI brain spine is necessary to rule out any other etiologies such as brain tumor or spinal pathologies. Features strongly supporting the diagnosis of Guillain-Barré syndrome include a progression of onset over several days to less than 4 weeks, symmetrical involvement, painful onset, mild/absent sensory symptoms, cranial nerve involvement, autonomic dysfunction, absence of fever, and recovery 2 to 4 weeks after the onset of peak or plateauing of symptoms.
Rahul Let's start with a...