What is the probable diagnosis and management for a patient complaining of loss of strength and tingling sensation in all limbs since last night, with possible Differential Diagnoses (DD)?

Acute Bilateral Limb Weakness with Paresthesias: Probable Guillain-Barré Syndrome

This patient presenting with acute onset bilateral limb weakness and tingling in all extremities since last night most likely has Guillain-Barré syndrome (GBS), which requires immediate hospitalization, respiratory monitoring, and consideration for immunotherapy. 1

Key Diagnostic Features

The clinical presentation strongly suggests GBS based on:

• Acute/subacute onset with bilateral ascending weakness and distal paresthesias, which is the hallmark of GBS 1
• Rapid progression with maximum disability typically occurring within 2 weeks 1
• All four limbs involved with both motor (weakness) and sensory (tingling) symptoms 1

The American Academy of Neurology emphasizes that rapidly progressive bilateral ascending weakness starting in legs and ascending to arms, combined with decreased or absent reflexes and distal paresthesias, defines the classic GBS presentation 1.

Critical Differential Diagnoses to Exclude

Compressive Cervical Myelopathy

Urgent MRI of the entire spinal column must be obtained within 12 hours if there is any clinical suspicion of spinal cord compression, as this is superior to all other imaging modalities 1. The American College of Physicians notes that cervical myelopathy can present with bilateral upper extremity weakness, numbness radiating from the neck, difficulty controlling limbs, and wobbly gait 1. However, myelopathy typically does not cause symmetric involvement of all four limbs simultaneously with this acute onset 2.

Acute Limb Ischemia

While acute limb ischemia presents with loss of sensation and decreased strength, it is characterized by absent pulses, cold extremities, and typically affects lower limbs unilaterally or bilaterally at the aortic bifurcation 2, 3. The presence of tingling rather than complete sensory loss, and involvement of upper limbs, makes this diagnosis less likely 2.

Immediate Diagnostic Workup

Physical Examination Priorities

• Assess reflexes - decreased or absent reflexes support GBS 1
• Test for motor weakness pattern - look for ascending pattern starting distally 1
• Evaluate respiratory function - vital capacity and negative inspiratory force, as respiratory failure is a major cause of mortality in GBS 1
• Check for sensory level - presence of a sensory level suggests myelopathy rather than GBS 2

Laboratory and Electrodiagnostic Testing

• Electromyography and nerve conduction studies help differentiate between peripheral neuropathy, radiculopathy, and myelopathy, showing demyelinating or axonal patterns in GBS 1
• Lumbar puncture typically shows albuminocytologic dissociation (elevated protein with normal cell count) in GBS, though this may not be present in the first week 1

Immediate Management

Immunotherapy

Initiate treatment immediately with either intravenous immunoglobulin (IVIG) or plasma exchange as soon as the diagnosis is suspected, as these are equally effective and should not be delayed 1. The American Academy of Neurology emphasizes that early intervention significantly improves outcomes and reduces mortality 1.

Supportive Care

• Admit to intensive care unit for respiratory monitoring, as approximately 30% of GBS patients require mechanical ventilation 1
• Monitor vital capacity every 4-6 hours initially 1
• Initiate DVT prophylaxis with subcutaneous heparin given immobility 1

Symptomatic Treatment

For neuropathic pain and tingling, the American Pain Society supports duloxetine as Level IB evidence for neuropathic symptoms 1. However, pain management should not delay immunotherapy 1.

Critical Pitfalls to Avoid

• Do not delay imaging while pursuing conservative management if any alarm symptoms are present (severe neck/back pain, sensory level, bowel/bladder dysfunction), as this can lead to irreversible neurological damage from missed myelopathy 1
• Do not assume bilateral symptoms are benign or musculoskeletal - bilateral presentation can indicate serious central pathology like myelopathy or GBS 1
• Do not wait for confirmatory testing before initiating immunotherapy if clinical suspicion for GBS is high, as delays worsen outcomes 1
• Do not miss respiratory compromise - declining vital capacity requires intubation before respiratory arrest occurs 1

Alternative Considerations if GBS is Excluded

If electrodiagnostic studies and clinical course do not support GBS, consider:

• Acute sensory neuropathy - though this typically begins focally and progresses more slowly over weeks to months 4
• Functional neurological disorder - characterized by internal inconsistencies on examination, but this is a diagnosis of exclusion requiring positive signs like Hoover's sign or give-way weakness 5, 6
• Inflammatory myopathy - though this typically presents with proximal weakness rather than distal paresthesias 7