Letter to the Editor
Differential diagnosis of flaccid paralysis in paediatric medicine
Diagnóstico diferencial de parálisis flácida en pediatría
P. Molina-Giraldo, A. Ulate-Campos
, J. Petanàs-Argemí, M. Rebollo Polo, V. González-Álvarez
Corresponding author
Servicio de Neurología Pediátrica, Hospital Universitario Sant Joan de Déu, Barcelona, Spain
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Molina-Giraldo, A. Ulate-Campos, J. Petanàs-Argemí, M. Rebollo Polo, V. González-Álvarez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Molina-Giraldo" ] 1 => array:4 [ "nombre" => "A." "apellidos" => "Ulate-Campos" "email" => array:1 [ 0 => "adrianaulate@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Petanàs-Argemí" ] 3 => array:2 [ "nombre" => "M." "apellidos" => "Rebollo Polo" ] 4 => array:2 [ "nombre" => "V." "apellidos" => "González-Álvarez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neurología Pediátrica, Hospital Universitario Sant Joan de Déu, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diagnóstico diferencial de parálisis flácida en pediatría" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1408 "Ancho" => 854 "Tamanyo" => 93690 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Craniomedullary magnetic resonance imaging study. Sagittal T2-weighted sequence before contrast administration showing an intramedullary tumour from D5 to D9, and syringomyelia proximal to the tumour.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Guillain-Barré syndrome (GBS), an acute inflammatory polyneuropathy, is currently considered the most frequent cause of flaccid paralysis in children.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> It is characterised by acute areflexic paralysis with albuminocytologic dissociation and it is considered a neurological emergency.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2–4</span></a> Differential diagnosis of GBS offers a wide range of possibilities; the most important diseases to rule out are spinal canal compression, transverse myelitis, botulism, and cerebellar ataxia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Monitoring clinical progression and running complementary tests are the keys to definitive diagnosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a previously healthy 8-year-old boy who presented abdominal pain radiating to the back, subsequently associated with weakness in the lower limbs. The patient was referred due to suspicion of GBS. No recent history of infections or fever was reported. At admission, he presented a 20-hour history of ascending muscle weakness, paraesthesias, pain in the lower limbs, and decreased vesical sensation. He was afebrile upon physical examination, with stable ventilation parameters, Glasgow coma scale score of 15, symmetrical decreases in upper limb strength (4/5), and strength ratings of 2/5 in the right leg and 1/5 in the left. The patient reported significant pain when moving his legs, and plantar reflexes were flexor bilaterally. He also exhibited patellar tendon and Achilles tendon areflexia (1/4). Sensitivity could not be properly assessed because the patient did not cooperate. No abdominal or cremasteric reflex could be evoked. He did not present tremor, dysmetria, or truncal ataxia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Results from the first round of complementary tests were as follows: normal haemogram and serum electrolyte study; cerebrospinal fluid (CSF) analysis contained 281<span class="elsevierStyleHsp" style=""></span>mg/dL proteins, 61<span class="elsevierStyleHsp" style=""></span>mg/dL glucose, 10<span class="elsevierStyleHsp" style=""></span>red blood cells/mm<span class="elsevierStyleSup">3</span>, and 0<span class="elsevierStyleHsp" style=""></span>leukocytes/mm<span class="elsevierStyleSup">3</span>. We requested a neurological evaluation and an emergency magnetic resonance imaging (MRI) study of the spine given the suspicion of spinal compression syndrome. Craniospinal MRI with contrast showed an intramedullary tumour extending from D5 to D9 and syringomyelia with beaded cavities proximal to the tumour. The study revealed central cord signal alterations with a nearly holocordal spread and compatible with oedema. The solid component of the tumour showed increased uptake (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Differential diagnosis uses MRI to distinguish between ependymoma and glioma. Brain MRI results were normal. The patient underwent an emergency surgical procedure which achieved partial resection of the mass. The histological study classified it as an anaplastic ependymoma. In the following days, the patient reported increased strength and mobility in the upper and lower limbs. He is currently able to stand with assistance and is receiving chemotherapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">When GBS is suspected, various entities must be ruled out. One of the most important is spinal canal compression, which can also cause sudden-onset symmetrical flaccid paralysis accompanied by arreflexia in the initial stage of spinal shock. However, it may also present at a later stage with normoreflexia or hyperreflexia. Spinal cord compression requires emergency decompressive surgical treatment.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Lumbar pain, asymmetric paralysis, sensory level, and persistent bladder or intestinal dysfunction are findings which require aetiologies other than GBS to be considered.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,6</span></a> We should highlight that in presence of sudden flaccid paralysis and the previously described characteristics, a spinal MRI should be performed to rule out compressive diseases of the spinal cord, such as traumatic lesion, haemorrhage, intramedullary abscess, tumour, and transverse myelitis.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,5–7</span></a> In our case, the diagnosis of GBS was doubtful because of presence of abdominal pain radiating to the lumbar region at symptom onset, bladder symptoms, the asymmetric pattern of weakness, and absent cremasteric and abdominal reflexes. These symptoms led doctors to the correct diagnosis and treatment. Furthermore, the patient's elevated protein levels were another source of doubt, since this finding suggests of an entity other than GBS. However, we did not find any literature citing the maximum protein levels in GBS and we believe that this value should always be scrutinised closely.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">This study has not been presented at any of the SEN's Annual Meetings or any other meeting or congress. It has not received any funding, whether public or private. The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Molina-Giraldo P, Ulate-Campos A, Petanàs-Argemí J, Rebollo Polo M, González-Álvarez V. Diagnóstico diferencial de parálisis flácida en pediatría. Neurología. 2016;31:500–501.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1408 "Ancho" => 854 "Tamanyo" => 93690 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Craniomedullary magnetic resonance imaging study. Sagittal T2-weighted sequence before contrast administration showing an intramedullary tumour from D5 to D9, and syringomyelia proximal to the tumour.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome de Guillain-Barré en la infancia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Ortez" 1 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 317 | 17 | 334 |
| 2024 September | 567 | 20 | 587 |
| 2024 August | 606 | 30 | 636 |
| 2024 July | 750 | 33 | 783 |
| 2024 June | 496 | 27 | 523 |
| 2024 May | 601 | 30 | 631 |
| 2024 April | 482 | 23 | 505 |
| 2024 March | 556 | 34 | 590 |
| 2024 February | 724 | 37 | 761 |
| 2024 January | 834 | 32 | 866 |
| 2023 December | 597 | 45 | 642 |
| 2023 November | 790 | 52 | 842 |
| 2023 October | 882 | 52 | 934 |
| 2023 September | 681 | 29 | 710 |
| 2023 August | 591 | 33 | 624 |
| 2023 July | 580 | 25 | 605 |
| 2023 June | 533 | 21 | 554 |
| 2023 May | 720 | 36 | 756 |
| 2023 April | 517 | 30 | 547 |
| 2023 March | 477 | 24 | 501 |
| 2023 February | 631 | 34 | 665 |
| 2023 January | 391 | 25 | 416 |
| 2022 December | 367 | 26 | 393 |
| 2022 November | 493 | 49 | 542 |
| 2022 October | 413 | 34 | 447 |
| 2022 September | 373 | 26 | 399 |
| 2022 August | 365 | 24 | 389 |
| 2022 July | 294 | 21 | 315 |
| 2022 June | 280 | 29 | 309 |
| 2022 May | 348 | 33 | 381 |
| 2022 April | 334 | 35 | 369 |
| 2022 March | 307 | 19 | 326 |
| 2022 February | 409 | 30 | 439 |
| 2022 January | 376 | 31 | 407 |
| 2021 December | 274 | 30 | 304 |
| 2021 November | 373 | 24 | 397 |
| 2021 October | 406 | 23 | 429 |
| 2021 September | 316 | 52 | 368 |
| 2021 August | 367 | 28 | 395 |
| 2021 July | 305 | 45 | 350 |
| 2021 June | 346 | 34 | 380 |
| 2021 May | 295 | 32 | 327 |
| 2021 April | 762 | 69 | 831 |
| 2021 March | 515 | 43 | 558 |
| 2021 February | 392 | 28 | 420 |
| 2021 January | 335 | 52 | 387 |
| 2020 December | 402 | 44 | 446 |
| 2020 November | 378 | 30 | 408 |
| 2020 October | 167 | 18 | 185 |
| 2020 September | 263 | 31 | 294 |
| 2020 August | 247 | 8 | 255 |
| 2020 July | 257 | 25 | 282 |
| 2020 June | 229 | 32 | 261 |
| 2020 May | 201 | 28 | 229 |
| 2020 April | 222 | 19 | 241 |
| 2020 March | 254 | 14 | 268 |
| 2020 February | 273 | 32 | 305 |
| 2020 January | 193 | 16 | 209 |
| 2019 December | 176 | 15 | 191 |
| 2019 November | 145 | 18 | 163 |
| 2019 October | 165 | 16 | 181 |
| 2019 September | 147 | 14 | 161 |
| 2019 August | 123 | 21 | 144 |
| 2019 July | 189 | 28 | 217 |
| 2019 June | 199 | 31 | 230 |
| 2019 May | 402 | 41 | 443 |
| 2019 April | 340 | 15 | 355 |
| 2019 March | 103 | 14 | 117 |
| 2019 February | 69 | 13 | 82 |
| 2019 January | 76 | 8 | 84 |
| 2018 December | 48 | 4 | 52 |
| 2018 November | 42 | 6 | 48 |
| 2018 October | 61 | 20 | 81 |
| 2018 September | 22 | 5 | 27 |
| 2018 August | 13 | 3 | 16 |
| 2018 July | 19 | 1 | 20 |
| 2018 June | 19 | 1 | 20 |
| 2018 May | 17 | 0 | 17 |
| 2018 April | 21 | 1 | 22 |
| 2018 March | 11 | 1 | 12 |
| 2018 February | 10 | 1 | 11 |
| 2018 January | 16 | 2 | 18 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 12 | 0 | 12 |
| 2017 October | 4 | 4 | 8 |
| 2017 September | 9 | 1 | 10 |
| 2017 August | 11 | 1 | 12 |
| 2017 July | 21 | 1 | 22 |
| 2017 June | 16 | 5 | 21 |
| 2017 May | 27 | 9 | 36 |
| 2017 April | 11 | 4 | 15 |
| 2017 March | 13 | 38 | 51 |
| 2017 February | 5 | 2 | 7 |
| 2017 January | 13 | 1 | 14 |
| 2016 December | 19 | 2 | 21 |
| 2016 November | 23 | 6 | 29 |
| 2016 October | 22 | 4 | 26 |
| 2016 September | 44 | 3 | 47 |
| 2016 August | 7 | 1 | 8 |
| 2016 July | 0 | 1 | 1 |
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