What is the most likely diagnosis for a patient with ascending muscle weakness, areflexia, and sensory involvement following a URTI?

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Guillain-Barré Syndrome

The most likely diagnosis is D. Guillain-Barré syndrome (GBS), based on the classic triad of ascending weakness, areflexia, and preceding upper respiratory tract infection. 1

Clinical Reasoning

This patient presents with the pathognomonic features of GBS:

  • Ascending pattern of weakness: Started in lower limbs and progressed upward to upper limbs, which is the classic presentation of GBS 1, 2
  • Areflexia: Total absence of reflexes in all limbs is a cardinal feature, present in almost all patients at nadir 1, 2
  • Sensory involvement: Tingling sensation (paresthesias) and moderate sensory symptoms are common in GBS, though not required for diagnosis 2, 3
  • Preceding infection: Upper respiratory tract infection weeks before onset is typical, as GBS is triggered by infections in approximately two-thirds of cases 1, 4
  • Acute onset with rapid progression: Two-day history fits the acute-to-subacute timeframe, as most patients reach maximum disability within 2 weeks 1
  • Pain preceding weakness: Muscle pain is frequently reported and can be muscular, radicular, or neuropathic in nature 1, 5

Why Other Diagnoses Are Less Likely

Viral myelitis (Option A) would typically present with:

  • Upper motor neuron signs (hyperreflexia, positive Babinski sign) rather than areflexia 6
  • Sensory level on examination 6
  • Bladder/bowel dysfunction early in the course 6

Epidural abscess (Option B) would show:

  • Severe localized back pain as the predominant feature 6
  • Fever and systemic signs of infection 6
  • Rapid progression over hours to days, not the ascending pattern described 6

Transverse myelitis (Option C) would demonstrate:

  • Clear sensory level on the trunk 6
  • Upper motor neuron signs with hyperreflexia below the lesion 6
  • Early sphincter dysfunction 6

Critical Diagnostic Pitfalls

Common mistake: Dismissing GBS because reflexes can occasionally be normal or even exaggerated in the pure motor variant with AMAN subtype, but this patient has total areflexia which is classic 1

Important caveat: If progression continues beyond 4 weeks from onset, consider acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP), which occurs in approximately 5% of patients initially diagnosed with GBS 7, 5

Immediate Next Steps

This patient requires urgent evaluation given the potential for rapid deterioration:

  • Neurologic consultation immediately 1, 2
  • Respiratory function monitoring using the "20/30/40 rule": vital capacity <20 mL/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O indicates risk of respiratory failure 2
  • MRI of spine with or without contrast to rule out compressive lesions 1, 2
  • Lumbar puncture: Expect elevated protein with normal or mildly elevated white blood cells (albuminocytologic dissociation) 1, 2
  • Electrodiagnostic studies to confirm peripheral nerve dysfunction and distinguish between AIDP, AMAN, and AMSAN subtypes 1, 7
  • Admission to unit with ICU capability given 20% of GBS patients develop respiratory failure requiring mechanical ventilation 1

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Guillain-Barré Syndrome: Clinical Presentation and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Diagnosis, treatment and prognosis of Guillain-Barré syndrome (GBS).

Presse medicale (Paris, France : 1983), 2013

Research

To be, or not to be… Guillain-Barré Syndrome.

Autoimmunity reviews, 2021

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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