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Internal Medicine

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A 29-year-old woman has the rapid onset of ascending paralysis. Her CSF exam is normal except for an elevated protein (90 mg/dl). Two weeks before her weakness began, she had an influenza immunization. Ten days prior to the onset of weakness, she had a febrile gastroenteritis for which she received a fluoroquinolone. Her fever and diarrhea resolved after three days.



Which one of the following is the most likely related to her paralytic illness?

  • Influenza vaccine

  • Cytomegalovirus

  • Campylobacter

  • Mycoplasma


N G

The most common cause of acute ascending neuromuscular paralysis is Guillain-Barré. The disease is symmetrical and slowly progressive from most distal to proximal. Lack of reflexes and dysautonomia are characteristic. There is no specific diagnostic test although the CSF often shows an elevated protein but normal cell counts (albuminocytologic dissociation).

Campylobacter is the most common and well-established infection associated with subsequent development of Guillain-Barré syndrome. Other infections that have been linked with this disease include HIV, CMV, and influenza. Zika virus infection has also been reported to cause Guillain-Barré syndrome. The presumptive mechanism of infection-related Guillain Barre syndrome is production of an antibody that cross-reacts with host peripheral nerve components because of shared epitopes (i.e., molecular mimicry).

An increased incidence of Guillain-Barré followed influenza immunization for swine flu in 1976-77. Subsequent studies have not confirmed an association between influenza vaccine and Guillain-Barre syndrome. Quinolones may produce a variety of neuropsychiatric side effects, but not Guillain-Barré.

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