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Internal Medicine

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A 19-year-old young woman has had a slowly progressive ascending paralysis over the last two days. She can no longer walk. One week before she developed neurologic symptoms, she had an episode of fever, cramping abdominal pain, and diarrhea that lasted three days.


Which one of the following was the most likely cause of her gastrointestinal illness?

  • Shigella sonnei

  • Clostridium botulinum

  • HSV

  • Enterovirus


Guillain-Barre is the most common cause of acute neuromuscular paralysis in the world. Many cases follow an obvious antecedent infection and many such infections have been described. One of the most common of these, if not the most common, is gastroenteritis due to Campylobacter jejuni. Other precipitating infections include cytomegalovirus, Epstein-Barr virus, HIV, and Zika virus. The presumptive mechanism for this syndrome is that the antecedent infection evokes an autoimmune response that cross-reacts with peripheral nerve components because of shared epitopes (i.e., molecular mimicry), resulting in an acute ascending demyelinating polyneuropathy. This immune response is directed against the myelin or the axon of peripheral nerves.

Shigella produces febrile diarrhea and may be associated with seizures but not a Guillain-Barre like illness.


Clostridium botulinum is a very rare cause of GI symptoms other than constipation as part of infant botulism; botulism is a descending paralytic illness.

HSV causes meningitis or encephalitis but is not associated with a Guillain-Barré- like syndrome. Enteroviruses can cause diarrhea and aseptic meningitis but not Guillain-Barré syndrome, although there is mounting evidence that enterovirus D68 is associated with acute flaccid paralysis in children.

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