Objective:

To describe a complex case and diagnostic approach of new onset flaccid paralysis in a patient with co-existing c-spine pathology and a baclofen pump.

Background:

Causes of flaccid paralysis are broad and pose a diagnostic challenge. Co-existing spinal pathology can complicate the presentation. There is scarce literature on flaccid paralysis with a co-existing motor pathology, but this case was also complicated by the presence of a baclofen pump.

Design/Methods:

Case report

Results:

A young male with chronic cervical spinal cord injury presented with unresponsiveness and hypoxia. He was wheelchair bound at baseline, with appropriate strength in upper extremities. He was initially treated for aspiration pneumonia and respiratory failure. Following extubation and improvement in mental status, he had progressive decline in his upper extremity strength, despite wean and eventual cessation of his baclofen pump. He developed widespread flaccid paralysis and lost his cough and gag reflex prompting CSF studies. Results were consistent with albuminocytological dissociation and negative microbial screen (CSF protein 179, WCC 5). He was treated for suspected AIDP with PLEX with differentials of critical illness polyneuropathy and baclofen toxicity. Upon weaning off the baclofen, patient was noted to have improved mentation without motor/tone improvement. EMG/NCS findings were limited by chronic denervation and were nondiagnostic. The following tests were negative/inconclusive; serum/CSF; West Nile Virus, MS panel, serum; HTLV-1, Myasthenia gravis panel, Coxsackie virus panel, Lyme, Rickettsia, EBV, Aquaporin-4 and MOG, CSF encephalitis panel. The case was determined to be an ascending flaccid paralysis initially masked by existing spinal cord injury and paraplegia, overall consistent with AIDP.

Conclusions:

Investigating flaccid paralysis often requires extensive investigations which can be narrowed down based on the clinical presentation and examination. Concomitant chronic c-spine pathology and presence of baclofen pump in this case masked a clear presentation of ascending paralysis prompting a very extensive workup and empiric treatment.