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A 63-year-old man presented to his local hospital with a 2-month history of general lethargy, fatigue and progressive weakness around his both shoulders and right arm. He also had neck pain radiating into his shoulders and back, with Lhermitte's phenomenon. There was no preceding trauma and no bladder or bowel incontinence. His background history included pleurodesis for left pneumothorax and a ruptured mesenteric cyst. He had developed multiple bowel adhesions requiring further laparotomy, small and large bowel resections and a resulting permanent ileostomy and short bowel syndrome. He required total parenteral nutrition via a central line. The postoperative period was complicated by an enterocutaneous fistula and stent insertion for acute cholangitis. He had received multiple courses of antibiotics in the preceding months. His other medical history included hiatus hernia and diverticular disease. However, there was no history of spinal or central nervous system (CNS) procedures and no history of diabetes mellitus. His drug history included loperamide, codeine phosphate, omeprazole and paracetamol. He had a history of suspected penicillin allergy.
He was a retired solicitor who lived with his wife and son; he was an ex-smoker (stopped 30 years earlier) with moderate alcohol intake. His travel history included travel to Mexico, Egypt, Malaysia and India several years before, but with no overseas illness.
On examination, he was afebrile. There was proximal upper limb weakness Medical Research Council grade 2/5 in shoulder abduction and distal weakness 2/5 right and 3/5 left in finger extension. His leg strength was normal. Tone was normal, as were sensation and reflexes, with no Hoffman's reflex.
Cerebrospinal fluid (CSF) sampling showed a markedly raised protein (35.3 g/L (0.13–0.45)), low CSF glucose at 1.3 mmol/L (with normal plasma glucose of 5.6 mmol/L) and a mixed neutrophil and lymphocytic picture (35 white cells/µL (≤5) comprising 31 neutrophils and four lymphocytes). Cytology showed no …
Contributors AM acquired the clinical data and wrote the manuscript. ZM wrote the manuscript and revised the manuscript for critical content. MT interpreted histology, created figure and revised the manuscript for critical content. CC, DC and CM acquired the clinical data and revised the manuscript for critical content.
Funding AM reports that she has received salary funding from the Health Service Executive (HSE)/Dr Richard Steeven's scholarship and UCC Ainsworth prize. This work was supported by the NIHR Queen Square Dementia Biomedical Research Unit and was performed at UCLH which receives funding in part from the Department of Health NIHR Biomedical Research Centre.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Nick Davies, London, UK.