Physical Examination and Work-up
The physical examination reveals an afebrile, ill-appearing teenager, with a heart rate of 118 beats/min, a respiratory rate of 28 breaths/min, a blood pressure of 168/122 mm Hg, and an oxygen saturation of 93% while breathing room air. Auscultation of the lungs reveals diffuse, poor aeration. His heart sounds are normal, without any appreciable murmur. His strength is symmetric but diminished to 2/5 in his lower extremities and 4/5 in his upper extremities (5/5 being normal strength). The patient's sensation is intact to light touch, but he has a loss of vibratory sense. He has no deep tendon reflexes in his lower extremities, diminished deep tendon reflexes (1+) in his upper extremities, and absent plantar reflexes. Cranial nerves II-XII are intact; however, he has a weak cough and gag reflex, with impaired handling of secretions. The remainder of his examination is unremarkable.
The patient is intubated for progressive respiratory distress and loss of airway-protective reflexes. He is fluid-resuscitated with a liter of intravenous normal saline. An electrocardiogram (ECG) is obtained, which demonstrates sinus tachycardia. The initial laboratory analysis, including a complete blood cell (CBC) count and a basic metabolic panel, is within normal limits. A lumbar puncture is performed, with an opening pressure of 15 cm H20. The cell count and Gram stain of the cerebrospinal fluid (CSF) demonstrates 2 white blood cells per high power field, 4 red blood cells per high power field, and no organisms. Additional analysis of the CSF shows a protein concentration of 96 mg/dL (960 mg/L) and glucose concentration of 72 mg/dL (3.99 mmol/L). The patient is sent for MRI of his brain and spine (see Figure 1) and is transported to the pediatric intensive care unit (ICU) for further management.
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