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Answers on p 444.
A previously fit and well 32 year old man was admitted to the neurology ward in November 1998 with a 24 hour history of rapidly progressive leg weakness such that he was unable to stand. He felt tingling in his hands and lower legs, but no loss of sensation. Two weeks earlier he had noticed intermittent weakness in both legs. He reported no other neurological or constitutional symptoms. Twelve weeks earlier he had returned from a holiday in California.
His past medical history was unremarkable except for bronchial asthma controlled by salbutamol and beclomethasone inhalers. On further questioning, he admitted to unusually more colds than normal as well as mild fatigue and tiredness of six months' duration.
On examination, he was tanned with palmar crease and buccal pigmentation. His pulse was regular at 80 beats/min, blood pressure was 130/60 mm Hg (unable to stand to check postural drop), and his temperature was normal. The remaining general physical examination was normal. Higher mental function, cranial nerves, and speech were normal. His upperlimbs were stiff with a supinator catch but normal power, sensation, and coordination. The tone in his lower limbs was raised, with severe pyramidal distribution weakness. All the deep tendon reflexes were very brisk with flexor plantars. Pinprick sensation was subjectively diminished in both feet with no sensory level. Other sensory modalities were intact. Magnetic resonance imaging of the brain and spine were normal. Routine investigations revealed a normal full blood count, sodium concentration 116 mmol/l, potassium 8.9 mmol/l (confirmed on repeated sample), urea 17.2 mmol/l, creatinine 165 mmol/l, glucose 5.8 mmol/l, bicarbonate 15 mmol/l, chloride 86 mmol/l, and serum calcium was normal. Thyroid function was normal. An electrocardiogram is shown in fig1.
- Describe the changes in the electrocardiogram
- How would you explain the neurological symptoms and signs?
- What is the final diagnosis and how would you confirm it?
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