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High neutrophils, high protein, low glucose, high opening pressure
13%
46/341
High lymphocytes, normal protein, normal glucose, normal opening pressure
16%
53/341
High lymphocytes, high protein, low glucose, high opening pressure
17%
59/341
Normal cell count, high protein, normal glucose, normal opening pressure
36%
124/341
Normal cell count, normal protein, normal glucose, normal opening pressure
6%
19/341
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The patient's clinical presentation is most consistent with Guillain-Barre syndrome. Cerebrospinal fluid (CSF) analysis in this syndrome is notable for "albuminocytologic dissociation," meaning that there is increased protein with a normal cell count, glucose, and opening pressure. Guillain-Barre syndrome is a demyelinating polyneuropathy caused by autoimmune attack of Schwann cells in the peripheral nervous system. Typical symptoms are ascending weakness, with relative preservation of sensation. The syndrome often occurs following infection with Campylobacter jejuni, although it can also occur following herpes virus infection, vaccines, and stress. The diagnosis is supported by a lumbar puncture showing increased protein with a normal cell count, and treatment consists of plasmapheresis and intravenous immunoglobulins (IVIG). The most feared complication is respiratory failure due to progression of the demyelination to the cervical nerve roots. Walling and Dickson review the diagnosis and treatment of Guillain-Barre syndrome. They note that, in addition to weakness, more than half of patients experience severe pain, and two-thirds of patients experience autonomic dysfunction. Roughly 3% of patients die, 20% of patients have long-term neurological effects, and 10% of patients become severely disabled. However, full recovery remains the most likely outcome. Kwong et al. perform a case-control study to determine the risk of developing Guillain-Barre syndrome after influenza vaccination versus after influenza infection. They include 2831 patients and find that the attributable risk of Guillain Barre syndrome after influenza vaccination is one per million vaccinations, while the risk after influenza infection is 17 per million infections. Therefore, they conclude that the risk of Guillain-Barre syndrome should not be a deterrent from influenza vaccination. Illustration A depicts the mechanism of antigen mimicry in Guillain-Barre. Illustration B lists different infectious precipitants of Guillain-Barre. Incorrect Answers: Answer 1: This is consistent with bacterial meningitis. Answer 2: This is consistent with viral meningitis. Answer 3: This is consistent with crypotococcal meningitis. Answer 5: This is consistent with normal CSF.
4.1
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