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 BOF 16

 

   

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BOF: 16

A 40-year-old male presents with a 3-day history of progressively worsening headaches, giddiness and seeing double. He also complained of a dry mouth and difficulty swallowing.

His wife said that his face had looked asymmetrical over the last few days.

He has no numbness or paraesthesiae. No gastrointestinal symptoms.

Four days prior to onset of symptoms   he head pricked his finger on a bougainvillea thorn.

On examination, he was alert and orientated in place, time and person. Pulse rate 62-beats/min regular, BP 120/80 mmHg, temperature 38.2 C.

CNS examination revealed ptosis, large poorly reactive pupils

He had diplopia on looking to the extremities horizontally (both sides)

There was difficulty in closing his eyes

He was unable to puff out his cheeks

He choked when asked to swallow water.

Power reduced in the upper limbs and lower limbs.

Deep tendon reflexes depressed

Sensation normal

The finger that had been injured looked red and inflamed

Investigations:
Hb 13.5g/dl
WCC 12.0 x 109/l
Platelets 200 x 109/l
Plasma sodium 138 mmol/l
Plasma potassium 4.2 mmol/l
Plasma urea 6.5 mmol/l
Plasma glucose 7.2 mmol/l

Lumbar puncture was performed

CSF showed
Opening pressure 14 cm H2O
Cell count <2 per mm3
CSF protein 0.2 g/l
CSF glucose 6.2 mmol/l

In this patient what is your most likely diagnosis?

a)      Guillain Barre syndrome

b)      Tetanus

c)      Myasthenia gravis

d)      Botulism

e)      Miller Fisher syndrome

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