What a Stiff!

A 21-year-old man had chills, fever, headache, nausea, and diarrhea for two days, after which he felt better. Two days later, however, his headache returned along with back pain and neck stiffness. The following morning, he awoke with pain and weakness in both his arms, the right more than the left. During the rest of that day, the weakness worsened, and he began to have trouble speaking clearly.
 

On examination that evening, he was dysarthric with shallow respirations. He yawned repeatedly and complained of shortness of breath. His neck was stiff. His gag reflex was absent, and his soft palate did not elevate on phonation. The other cranial nerves functioned normally. His muscles were tender to palpation. The right arm was completely paralyzed except for slight movement of the fingers, and the left shoulder girdle muscles were weak. Strength in the legs was normal. Deep tendon reflexes were absent in the arms but normal in the legs. The plantar reflexes were flexor. Sensory examination was entirely normal.
 

His breathing worsened progressively, and he was intubated and placed on a mechanical ventilator the following morning.

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