A case of paralysis, cured in the emergency department

I open my car door to walk in to work. I’ve never heard crickets as loud as the ones this summer in Georgia. A wall of steam-heat blasts me simultaneously as a giant bzzz! bzzz! dive-bombs my ear. Man, it’s hot in Georgia. And the bugs! I think to myself. I walk slowly towards the ED doors, barely moving, but still breaking a sweat. I walk through the double doors now enveloped by my refrigerated workplace.

I pick up my first patient, tagged non-urgent: “6-year-old girl. Legs paralyzed.”

That’s weird, I think to myself. Paralyzed? Non-urgent? Not a trauma? I walk in the room and there is a 6-year-old girl, sitting on the stretcher smiling, unconcerned. Her dad looks only slightly more concerned.

“I can’t move my legs,” says the girl. “I was fine this morning, then after lunch, my legs started getting weak.”

“Has she had any other symptoms like fever, headache, or weakness in the arms? How about, double vision? Rash, trouble swallowing, abdominal pain?” I ask.

“No,” she says, with the infectious smile of a 6-year-old, as her dad also shakes his head in agreement.

“Was she exposed to any chemicals,” I ask her father, “any sprays, or pesticides?”

“Nothing at all,” he answers, puzzled.

“La belle indifference,” I think to myself. Maybe this is conversion disorder. I do a full exam. Everything is normal, except for the fact that her legs do seem weak: very weak in fact, almost flaccid. And her leg reflexes: almost non-existent. It’s not a complaint you see every day in children, especially ones without trauma or a spinal cord injury. I go back to the physician charting area. I discuss the case with a few of my partners.

“Is she faking?” asks Dr. Bill, 15 years my senior. “It’s probably factitious disorder. Remember, this department’s exploding with sick people right now.”

“I vote for Guillan-Barré,” says Dr. Susan. “I also saw a kid with a spontaneous intracranial hemorrhage of the cerebellum once from an arteriovenous malformation and it presented sort of like this, but more with ataxia than weakness. You need to do a CT, lumbar puncture, labs, and turf to peds.”

“Is there any double vision, or extra-ocular muscle weakness? I saw one like this 6 months ago. It turned out to be myasthenia gravis,” says Dr. Jim, as he leans over with a pained look on his face, scratching his legs violently. “You got anything for mosquito bites on you? Hydrocortisone cream, anything? I’m dyin’ here from these bites.”

Whatever this turns out to be, it isn’t going to be something you see every day in the emergency department. I click on “board exam questions” in the hard drive of my brain.

Miller Fisher syndrome? Lambert Eaton myasthenic syndrome? Organophosphate poisoning? Botulism? Some weird electrolyte imbalance? Encephalitis? Some rare porphyria variant? I’m digging deep, grasping.  She may need labs, brain CT, and possibly a lumbar puncture just to start. I walk back into the room to start over. Something doesn’t feel right about this. I sit down to take the history again.

“Doc, I wanna’ ask you something … ” says the dad.

“Just a minute, let me examine her again,” I say, concentrating. I examine her again from head to toe, this time with my best textbook Physical Diagnosis exam. Her arms seem a little weak now, too. Or am I imagining it?

Beep! screams a monitor from outside the room.

“Doc, one more thing …” he tries to add.

“Trauma alert room 11!” comes jolting out of the overhead speaker. As I start to bolt out of the room, I glance out the door and white-haired Dr. Bill sprints into room 11 faster than someone 20 years younger. He beat me to it. I walk back into the room with the girl.

“Hold on,” I say. “Let me finish my exam, please.”

Here is a perfectly healthy 6-year-old, who for no reason, all of a sudden can’t move her legs.

“Doc, one more thing …”

“Yes?” I answer.

“As an aside, I almost forgot. No, forget it, I don’t want to waste your time …” he trails off.

“No, what is it?”

“Okay. I hope I’m not wasting your time, but could you remove this?” he asks, pointing to his daughter’s head.

I peel back the thick brown locks of hair on top of her head.

“Aha. That’s it!”

“What, is it?” says the dad, startled.

“It’s a tick!” I exclaim, as I look at the big, fat engorged tick, sucking blood from her head.

“I know it’s a tick. Can you remove it?”

“Yes, but that’s why she’s paralyzed. It’s the tick. Your daughter has tick paralysis.”

I gently grasp the tick with tweezers, pull slowly and very gently, and out comes the tick fully intact.

“She’s going to be just fine.”

“Tick paralysis? What’s that?”

“Believe it or not, certain ticks can release a toxin during their bite that can actually cause temporary paralysis in children. It is pretty rare and can be serious if undiagnosed, even life threatening. The good news is that all you have to do is remove the tick. Within a few hours, your daughter should be just fine. As a precaution, she’ll need to be admitted overnight to make sure the symptoms go away, and I suspect they will. If they don’t, she will need further testing.”

This was a girl that came to the emergency department carried by her father, unable to walk, paralyzed from the waist down. She would walk out of the hospital 24 hours later, whole again. It was a case of paralysis, truly cured in the emergency department. It was a simple and easy cure, within the skill set of anyone with a pair of eyes and tweezers, but truly fascinating nonetheless.

“BirdStrike” is an emergency physician who blogs at Dr. Whitecoat.

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  • rtpinfla

    Cool case.

  • medicontheedge

    Great case, I’ve seen the exact same thing presented at a rounds once… Sad, but true, most likely this patient would have been subjected to extensive costly examinations, even before the provider performed an actual “hands on” examination, in any ED. More often than not, batteries of test are ordered before the provider even sees the patient. Cases like this should be shown to all ED providers.

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