Acute Unilateral Tongue Paralysis in Evolving GBS
February 1, 2002 2 minutes read
Acute Unilateral Tongue Paralysis in Evolving GBS
Case Report
A 44-year-old man without any significant medical history awakened with left arm weakness. A few hours later he noticed left leg weakness and presented to the New York Hospital. On admission, his examination was notable for a striking left tongue deviation, left hemiparesis, proximal (MRC grade 1-2/5) more than distal (MRC 4/5) weakness in both arm and leg, and hypoflexia throughout with flexor response of the toes. A presumed diagnosis of ischemic stroke in the medullary area by the graduate staff was considered but MRI of the brain showed no abnormality.
The next day, he developed difficulty swallowing and right-sided weakness. On examination, he now had a trace of right-facial weakness, slight deviation of the uvula to the right, and a new right-arm weakness (3-4/5). He had lost all of his motor reflexes except those of the right biceps and triceps. Sensation was perfect. Nerve conduction study showed a wave (57.3) in the left peroneal nerve and a conduction block across the elbow in the left ulnar motor nerve. His CSF contained a protein of 45 and glucose of 70, with 0 WBC. A diagnosis of Guillain Barré Syndrome (GBS) was made and he was treated with IVIG.
Commentary
Acute hemiparesis and unilateral tongue paresis is a rare presentation in GBS. Occasionally the peripheral Miller Fisher syndrome is mistaken as a brain stem stroke due to opthalmoparesis, but we could not find a similar case in the literature of GBS to present such a severe lingual hemiparesis that it appeared to have an upper motor neuron stroke. In retrospect, there was a subtle sign such as the evolving distribution of weakness and lack of stretch reflexes in the left limbs. Unilateral, semi-isolated tongue weakness is rare in every case. Facial nerve is the most common cranial nerve affected in GBS. In some reports, bilateral tongue weakness is reported in about 20% of the GBS patients (Winer JB, et al. J Neurol Neurosurg Psychiatry. 1988;51:613-618), but it is usually bilateral. In his 100 cases of tongue paralysis that Keane reported, 4 were to be from GBS, but only 1 had unilateral tongue paresis (Keane JR. Arch Neurol. 1996;53:561-566). —Fred Plum & Michiko K. Bruno
Dr. Plum, University Professor, Weill Medical College, and Attending Neurologist, New York Presbyterian Hospital, is Editor of Neurology Alert. Dr. Bruno is Chief Resident, Department of Neurology & Neuroscience, New York Presbyterian Hospital, New York, NY.
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