Ninth Case : Back to the Swing

After getting such a long and unexpected respite you were fresh and ready for some new fun at the job . you hadn't seen a child patient lately and the pediatrician inside you was longing for some satisfaction . That's when a patient answers your call in the form of a 6-year-old female with no significant medical history pre-senting with one day of weakness and inability to move her left arm. She denied trauma to the arm, pain or numbness. On examination, her left arm was completely flaccid (strength 0/5) with intact sensation and a normal radial pulse.Radiographs of the left arm and a non contrast CT of the brain were obtained. Both tests were normal, and the patient was admitted to the pediatric service. On hospital 2nd day an MRI of the neck was obtained, which was again normal. By this time, the patient had regained most of the strength in her left arm, that's when you discharged her home with the diagnosis of left brachial plexitis (ahh your brain waves). Eight days following discharge,the patient again presented to the ED, now with the chief complaint of left leg weakness (now what . . . ? ), plus there was worsening weakness in her left arm. Sh ewas having difficulty walking secondary to the leg weakness. She denied pain or numbness to the arm, and her parents denied recent trauma,fevers, illnesses,travel or sick contacts. Again you go for PE and find the following out :

GENERAL APPEARANCE: well nourished, well hydrated, nontoxicand in no acute discomfort.

VITALS
Temperature 98.2 F
Pulse 95 beats/minute
Blood pressure 100/60 mmHg
Respirations 20 breaths/minute
Oxygen saturation 100% on room air

Head Eyes & ENT: PERRL,EOMI, oropharynxpink and moist.

NECK: Supple, no midline tenderness,no meningeal signs.

CARDIOVASCULAR: Regular rate and rhythm without rubs, murmurs or gallops.
(Check out the Figure ) Coronal views of MRI of the brain (FLAIR image,panel A; T2-weighted image, panel B) from a 6-year-old female with left arm and leg weakness.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nontender,nondistended.

EXTREMITIES: No clubbing, cyanosis or edema; strong and equal peripheral pulses,upperand lower extremities.

NEUROLOGIC: Alert and oriented to person, place and time; cranial nerves II–XII grossly intact. Right upper and lower extremity strength 5/5 proximal and distal, left upper extremity strength 3/5, left lower extremity strength 2/5. Bilateral knee, ankle and biceps reflexes 2+. Patient could ambulate but witha slow, wide-based gait.


you drew the blood and sample was sent for laboratory testing, and MRI of the brain was obtaine(Figure).Laboratory tests,including a complete blood count, electrolytes, creatinine, glucose and INR, were within normal limits.


what are the differentials , probable diagnosis and how do you wish to to proceed ??