Hot Seat #261: A wobbly situation
Posted on: August 5, 2026, by : Brittany Fitzpatrick
Case by Sarah Benett, CNH PEM Fellow
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.
CBC, CRP, CMP, and CK all within normal limits. Patient noted to previously be positive for Flu A so RVP not repeated. CT head also completed and was normal.
LP attempted and unsuccessful x2. Decision made by neurology to admit patient to their service for sedated LP and MRI Brain/Spine.
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This can be a very long response. Just to start with broad ideas, I would first ask: Is the adolescent unable to walk because of pain, weakness, or ataxia?
Very broadly, pain can be assessed by palpation and by trying to reproduce symptoms; weakness by the motor examination; and ataxia by looking for truncal ataxia (e.g., sitting unsupported) and limb dysmetria (finger-to-nose testing).
If pain is the primary problem, the differential can include influenza-associated myositis/rhabdomyolysis, trauma, and inflammatory or neurologic conditions in which pain can accompany weakness, including GBS and transverse myelitis.
Weakness is likely the primary focus in this case. It could initially be attributed to the influenza illness or dehydration, but the abnormal neurologic findings make that explanation insufficient. Thinking anatomically, I would divide the differential into:
• Spinal cord: transverse myelitis, spinal cord infarction, compression/impingement
• Anterior horn cell: acute flaccid myelitis
• Peripheral nerve/root: GBS/AIDP or another acute inflammatory neuropathy
• Muscle: influenza-associated myositis/rhabdomyolysis or another inflammatory/infectious myopathy
• Metabolic: hypokalemia and other electrolyte abnormalities
• Other neurologic/inflammatory: ADEM or other CNS inflammatory disease
• Toxic/infectious: depending on the history, including botulism and other less common causes
Further exam information I am interested in: bladder US as indicator of not voiding completely and either rectal tone or gluteal squeeze. If these are abnormal, I would move sooner to SC imaging.
Finally, a functional disorder is certainly possible given the patchy neurological findings. A Neurology colleague taught me the Hoover sign: with the patient supine, place your hand under the hamstrings or ankle of one leg. Ask the patient to flex or raise the other leg, If your hand can feel a downward counterpressure when the other leg is raised, this suggests that the neural pathways are intact. The point is that a functional neurologic disorder is a diagnosis based on positive examination findings, not simply a diagnosis of exclusion.
Workup in the ED
First things first: acute weakness means assessing for respiratory compromise. This requires ongoing cardiorespiratory monitoring and frequent reassessment for tachypnea, increased work of breathing, weak cough, difficulty speaking/counting and considera baseline NIF/FVC – tricky to do because the PICU RTs do this.
Labs: would add electrolytes such as Mg and phos to the labs that were done.
What fits and what doesn’t: before calling our Neurology colleagues, I would try to weigh the differential rather than simply assume GBS.
The rapidity of onset and the pattern of weakness do not fit classic GBS particularly well, and the marked proximal/knee weakness with preserved ankle strength is somewhat unusual. Transverse myelitis remains important because of the bilateral weakness and sensory abnormality. AFM is also worth considering because it can produce acute flaccid weakness and hyporeflexia/areflexia after a viral illness. I’m not sure if the weakness typically involves the entire limb. ADEM is less likely because there is no encephalopathy or other clear multifocal CNS involvement.
A primary intracranial process seems less likely and emergent head CT may not be needed. The imaging question is whether there is a spinal cord process, in which case MRI would be much more informative than CT.
The questions I would bring to our Neurology colleagues is: How would they rank the differential given the tempo, pattern of weakness, areflexia, and sensory findings? Does the examination warrant urgent MRI of the spine, and is there any reasonable role for observation with serial examinations.