Ascending Paresthesia - Status Post Total Knee Replacement

HISTORY: A previously healthy 69-year-old male presented to the emergency room with worsening bilateral numbness and tingling of fingertips and toes. He underwent left total knee arthroplasty nine days prior. He reported increasing leg weakness with difficulty standing and walking. His post-surgical course was unremarkable, and he was recovering well with home physical therapy. He reported removing several tick bites recently. Patient denied new rashes, recent illness, travel, diarrheal episodes, vaccinations, headache, blurry vision, fevers, chills, shortness of breath or difficulty swallowing. PHYSICAL EXAMINATION: Neurological evaluation revealed intact sensation to pinprick, temperature and vibration in bilateral upper extremities, but decreased sensation to pinprick, vibration and temperature in length dependent pattern in bilateral lower extremities. Motor strength was diminished in the left lower extremity and bilateral upper extremities. Deep tendon reflexes were diminished bilaterally at the brachioradialis, patella and ankle. His coordination was poor with finger to nose test. Cranial nerves II-XII were intact. DIFFERENTIAL DIAGNOSIS: 1. Lyme disease. 2. Rhabdomyolysis. 3. Acute Transverse Myelitis. TEST AND RESULTS: Normal ESR at 15. Sodium low at 127. TSH at 0.6. Hgb A1c at 5.6. Vitamin B12 assay 1084. Folate 18.9. Lyme, Ehrlichia, Babesia, and Anaplasma antibody PCR tests were negative. Creatine Kinase at 106. CSF analysis revealed albuminocytologic dissociation with elevated protein at 61 and one nucleated cell. Bacterial cultures of CSF were negative. IgA elevated at 410. FINAL WORKING DIAGNOSIS: Guillain-Barré Syndrome status post Total Knee Arthroplasty TREATMENT AND OUTCOMES: The patient was admitted and started on IVIG treatment for Guillain-Barré syndrome secondary to post-inflammatory process caused by his knee replacement surgery. He received a total IVIG dose of 2 gm/kg divided into 0.4 gm/kg/day for 5 days. During his hospitalization, he remained autonomically stable, and showed improvement in paresthesia and weakness. The patient was discharged to short term rehabilitation facility for 10 days where he was able to regain his ability to walk. His paresthesia and weakness completely resolved after 2 months with outpatient physical therapy.