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A bad dose of 'flu
  1. G V McDonnell
  1. Correspondence to:
 Dr Gavin McDonnell, Department of Neurology Ward 21, Quin House, Royal Victoria Hospital, Belfast, Co Antrim, Northern Ireland, BT12 6BA, UK;
 gvmcdonnell{at}doctors.org.uk

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A 42 year old right handed joiner presented with a five day history of cough, fever, and aching muscles. He had previously enjoyed good health. Three days into his current illness he had attended his general practitioner and been prescribed ibuprofen, aspirin, and a “cold remedy”. He had no history of recent overseas travel and other family members were well.

Over the 48 hours before hospital admission he had become much weaker and was eventually unable to walk unsupported. He was admitted to his local hospital for investigation and treatment.

At this time he complained of muscle tenderness and he found it uncomfortable to move his limbs. He had tingling in his right hand. He had also noticed that his urine had darkened in colour and his wife had noticed that his face had become swollen.

On examination he was alert, orientated, and apyrexic. There was facial oedema and all four limbs were also swollen, with marked muscle tenderness. The peripheries were cold and the urine was indeed dark brown. Neurologically, there was modest, but significant, weakness of finger abduction bilaterally (right: 4/5; left: 3/5) as well as proximal weakness in both legs (hip flexion: 4/5 bilaterally). Passive flexion at the knees was difficult due to pain. There was no objective sensory deficit and both plantar responses were flexor.

Investigations at this stage included measurement of haemoglobin (202 g/l), white cell count (12.2 × 109/l), erythrocyte sedimentation rate (10 mm/hour), urea (10.1 mmol/l), potassium (4.6 mmol/l), creatinine (78 μmol/l), and calcium (2.06 mmol/l). Chest radiography was normal.

QUESTIONS

  1. What is the most likely diagnosis and how would you confirm it?

  2. What is the possible aetiology of this condition?

  3. What potential complications may occur?

  4. How would you manage this patient?

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