A 25-year-old Malay man presented with a 3-day history of progressive symmetrical lower limb weakness with peripheral numbness. On the day before admission, he had low backache and difficulty in passing urine and faeces. On the day of admission, both hands were weak and he had difficulty swallowing. The background history included a 3-month history of chronic cough, intermittent fever and anorexia, with weight loss of 14 kg.

On examination, he was alert and orientated. There were multiple small submandibular lymph nodes. Cardiovascular examination was normal. There were inspiratory crepitations over the left lung base. He had mild dysarthria and diplopia at extremes of lateral gaze. His upper limb tone was normal. There was mild weakness of shoulder abduction and elbow flexion (Medical Research Council (MRC) grade 4/5) and moderate bilateral weakness (3/5) of wrist extension. His legs were flaccid with marked bilateral weakness of hip flexion, knee extension (MRC grade 1/5) and of ankle dorsiflexion (0/5). His deep tendon reflexes were absent throughout. There was reduced pain sensation in a stocking distribution and reduced joint position sense bilaterally.