15-year-old female with a history of ADHD, anxiety, and depression presented with acute bilateral lower extremity weakness. On the morning of presentation, she awoke around 8 AM and was unable to walk to the bathroom, requiring her to drag herself across the floor. Since onset, she reported inability to move her legs and decreased sensation in the right foot. Prior to transfer, she was evaluated at an outside hospital where she tested positive for Influenza A, received oseltamivir and acetaminophen, and was referred for concern for Guillain-Barré syndrome (GBS). 

She reported approximately 2 weeks of flu-like symptoms, with worsening cough, fever, and a severe generalized headache overnight prior to presentation. She also endorsed chest pain with coughing and persistent headache. She denied diarrhea, recent ingestion of undercooked poultry, contaminated water exposure, trauma, visual symptoms, bowel or bladder dysfunction, dyspnea, dysphagia, dysarthria, or upper extremity weakness. She was unsure whether weakness progressed in an ascending pattern but recalled her legs feeling “wobbly” overnight before complete inability to ambulate. No prior similar episodes were reported.  

Physical Examination 

Vitals: T 38.8C, HR 147, RR 20, BP 124/61, SpO2 97% on RA 

General: Alert, cooperative, age-appropriate, well appearing. 

HEENT: No pharyngeal erythema or exudate. 

Neck: Supple, no nuchal rigidity; reports muscular neck pain with rotation. 

Cardiovascular: Tachycardic, regular rhythm, normal perfusion, no murmurs. 

Respiratory: Clear to auscultation bilaterally, non-labored respirations. 

Abdomen: Soft, non-tender, non-distended. 

Neurologic: 

Cranial nerves II-XII intact. 

• Normal speech and mentation. 

• Upper extremity strength, sensation, and reflexes normal. 

• Lower extremities: 

• Hip flexion: 2/5 bilaterally 

• Knee strength: 0/5 bilaterally 

• Ankle strength: 5/5 bilaterally 

• Absent patellar and Achilles reflexes bilaterally. 

• Sensation intact over thighs and feet, but diminished/absent from ankles to knees bilaterally. 

Musculoskeletal: No back pain or joint tenderness.