Differential Diagnosis for Patient with Paraplegia and Transient Quadriplegia

The patient's symptoms of waking up with an inability to move upper extremities, despite having a previous spinal cord injury causing paraplegia, suggest a complex neurological condition. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Sleep Paralysis with Hypertonia: This condition is characterized by the inability to move or speak when falling asleep or waking up, often accompanied by hallucinations. In a patient with pre-existing paraplegia, the sensation of paralysis in the upper limbs during sleep paralysis could be particularly distressing and might be perceived as an inability to move these limbs. The fact that only facial muscles can be moved could be due to the patient's ability to partially overcome the paralysis in these muscles.

• Other Likely Diagnoses

  • Nocturnal Spasms or Seizures: Nocturnal seizures can manifest as sudden, brief episodes of loss of muscle control or abnormal movements, which could be perceived as an inability to move the upper extremities upon waking.
  • Sleep-Related Movement Disorders: Certain sleep disorders, such as restless legs syndrome or periodic limb movement disorder, could potentially cause discomfort or sensations that might be misinterpreted as an inability to move the upper limbs.
  • Psychogenic Causes: Conversion disorder or factitious disorder could manifest as paralysis or inability to move certain body parts, including the upper extremities, without an organic cause.

• Do Not Miss Diagnoses

  • Acute Spinal Cord Compression or Injury: Any new neurological deficit, especially one that involves a change in the level of injury or the development of new symptoms, must prompt an urgent evaluation for possible spinal cord compression or a new injury.
  • Pulmonary Embolism or Other Acute Medical Conditions: While less directly related to the neurological symptoms, conditions like pulmonary embolism can cause sudden respiratory distress and might lead to hypoxia, which could exacerbate or mimic neurological deficits.
  • Autonomic Dysreflexia: This is a life-threatening medical emergency that occurs in individuals with spinal cord injuries above the mid-thoracic level, characterized by a sudden, severe increase in blood pressure. It can cause a variety of symptoms, including neurological ones, and must be treated immediately.

• Rare Diagnoses

  • Guillain-Barré Syndrome: An autoimmune disorder that can cause rapid-onset muscle weakness, which might be perceived as an inability to move the upper extremities. It is rare but can be triggered by a variety of factors, including infections.
  • Myasthenia Gravis: An autoimmune disease characterized by weakness and rapid fatigue of the muscles under voluntary control, which could potentially cause symptoms similar to those described, especially if the patient has a pre-existing condition affecting mobility.
  • Botulism: A rare but serious illness caused by a toxin that affects the nervous system, leading to muscle weakness or paralysis. While unlikely, it could potentially cause the described symptoms in a patient with paraplegia.