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4. 1 and 3
The cause of his neurological picture is not entirely clear. He appears to have an acute quadraparesis with dysautonomia and hyporeflexia. This syndrome is classic for acute demyelinating radiculopathy or Guillain-Barré syndrome (1,2). His history suggests the possibility of wound botulism, but this usually affects muscles of the head and neck, and was not associated with dysautonomia. Also, no focal skin infection or skin-popping sites were apparent. Spinal cord compression was typically associated with hyperreflexia and Babinsky’s sign, but hyporeflexia and dysautonomia can be seen in acute high cervical lesions. Review of the emergency medical system records revealed that the patient had initially complained of being unable to move for the 24 hours prior to his admission, but this history was initially lost early in the admission when attention was focused on his altered mental status. His chest x-ray showed increased consolidation in his right lung most likely secondary to aspiration pneumonia – possibly related to respiratory failure due to neuromuscular weakness of the bellows.
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