This week’s case highlighted a child with lower extremity pain and weakness. Regarding initial imaging, the discussion focused on differentiating between pain and weakness. Weakness would prompt learners to lean more towards CT or MRI, which would provide more information and still include an evaluation of the bones and joint spaces.

Urgent sedated MRI brain and whole spine w/ and w/o contrast under sedation and LP performed. MRI demonstrated bilateral enhancement of the anterior cauda equina nerve roots, partial enhancement L 3rd CN, possible R 3rd CN concerning for polyradiculopathy of the anterior cauda equina nerve roots, left 3rd cranial nerve, and possibly the right 3rd cranial nerve. LP demonstrated albuminocytologic dissociation. Presentation with laboratory and imaging results were most concerning for abnormal presentation of Guillain-Barré Syndrome. Patient subsequently received 2 doses of IVIG, resulting in some improvement in weakness.

Patient was seen in the neuromuscular clinic for follow-up and had no real improvement despite inpatient rehabilitation and frequent PT since discharge. In addition, the patient was now having left lower extremity weakness. Additional testing included an EMG in March, which did not meet diagnostic criteria for Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), but as atypical motor predominant CIDP given initial diagnostic studies, was plausible, repeat MRI lumbar spine and CSF studies were conducted and were reassuring against ongoing CIDP. More studies were done, and ultimately, Neurology agreed that the initial presentation was most consistent with abnormal presentation of GBS with slower recovery.