Mr. C, a generally healthy Hispanic man aged 29 years, was brought to the clinic for generalized weakness. He was also having trouble moving, talking, and grasping. Mr. C was asymptomatic when he went to bed the night before, but his wife woke up and thought he was breathing in an odd manner. When Mrs. C awakened her husband, his speech was slurred, and he was making an unusual hand movement.

Mr. C had no history of head injury, seizure, fever, or incontinence. He had not travelled recently and noted no contact with sick individuals. Medical history was unremarkable for chronic medical problems, surgery, or periodic weakness.


Respiratory distress caused the patient to be unable to lie flat. Vital signs were stable with O2 saturation levels at 92% on two liters of oxygen.

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Head exam revealed no signs of trauma. The right pupil was miotic and had a sluggish reaction to light compared with the left. The patient had a right facial droop, was unable to protrude his tongue, and had slurred speech. Oral mucosa was moist, with absence of thyromegaly or jugular venous distention. Lungs were clear with shallow breath sounds. Heart exam was normal with no evidence of rub or murmur. Abdomen was benign. Mr. C was alert and oriented to time, place, and person. He exhibited bilateral 2/5 handgrip per Medical Research Council scale and had normal sensations but was unable to lift both legs off the bed.


ECG showed a normal sinus rhythm with no ischemic changes. Hemoglobin was 14.6 g/dL and WBC 10,400/μl, with 49% neutrophils and 45% lymphocytes.

International normalize ratio was 0.98. Chemistry revealed sodium 141 mEq/L, potassium 2.4 mEq/L, chloride 101 mEq/L, bicarbonate 27 mEq/L, glucose 149 mEq/L, creatinine 0.9 mg/dL, blood urea nitrogen 20 mg/dL, and calcium 9 mg/dL.

CT of the head showed no bleed or acute change (Figure 1).