Issue: 2016 > August > photo quiz

A 43-year-old woman with a quadriparesis

M. van der Toorn, S. de Klerk
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A 43-year-old woman presented to the emergency department with progressive weakness. Her medical history included the diagnosis of Crohn´s disease with multiple surgical procedures because of rectovaginal fistulas, a subtotal colectomy and terminal ileostomy. She required daily potassium chloride and fluoxetine. On presentation her partner carried her because weakness impeded her from walking. She complained of speaking difficulties, cramping sensation in her hands, stomach pain and vomiting with almost no intake in the last three days together with a fully productive stoma. In the foregoing days, she kept dropping things and she noticed having trouble walking. There was no history of traumatic injury. Physical examination revealed a cachectic woman with minimal diffuse abdominal tenderness. 
On neurological examination she could barely rotate her head. She experienced extreme difficulty lifting her arms. Examination of the legs also showed paresis with absence of tightening proximally and weakness distally. Reflexes were absent bilaterally in the upper and lower extremities. ECG showed a first-degree AV block with ST elevation in aVR and ST depression in several leads (figure 1). She worsened during her stay in the emergency department as she developed evident swallowing difficulties and progressed to imminent aspiration after a little sip of water.