Elissa’s Story

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Nurses Edition Commentary

Mizuho Morrison, DO, Kathy Garvin, RN, and Lisa Chavez, RN
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Jonathan W. -

Sounds like this was Heavy Metal poisoning that got better when the patient was removed from the toxic source.

Jonathan Wasserberger MD

Jess Mason -

Thanks for your comment. The R&D lab was a red herring in real life, so I wanted to include that in the segment. I should have mentioned that Elissa's diagnosis was ultimately confirmed by EMG and I think antibodies as well. Great thought on heavy metals, and important to keep on the ddx!
-Jess

Lars E., M.D. -

Fascinating case. While I appreciate the education about the varied presentations of GBS, I have difficulty accepting the recommendations provided in this chapter. Patients presenting to the ED with multiple non-anatomic neurolologic symptoms (numbness, weakness, paresthesias/dysesthesias) are very common. I think I had 3 of these cases my last shift. The conclusion of this chapter seems to be that GBS should be considered in these patients even when there is a lack of physical signs, i.e., that patients with odd, non-anatomic, atypical neurologic complaints should get an LP to assess for elevated protein. Let's ponder that for a moment: atypical GBS is very rare, perhaps 1 case per 100,000 per year. Lumbar puncture is not free of expense, ED physician time, patient throughput time/ED crowding, patient discomfort, and complications. Also, apparently early in the course of GBS the CSF is initially negative, so it is not clear that increasing the number of patients we LP is going to increase the number of early GBS diagnosis. The United States is not littered with the bodies of weak, nearly paralyzed patients with missed cases of atypical GBS. Are we really missing enough cases of this diagnosis that it justifies increasing the rate at which we perform LP on a patient's initial presentation when there are no objective findings?

Jess Mason -

I think one of the take home points is to increase your workup and level of suspicion when someone has multiple ED visits and isn't getting better. Remember to keep GBS on your differential, that it's not always a classic presentation, and the LP is a necessary part of the workup when GBS is being considered. Of course every emergency provider uses their own clinical acumen to decide when to pursue that workup, and the point is not to LP everyone, but to keep this in mind since it can present quite differently than how it is classically taught.

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