Ashley Takahashi, MD1, Bethany Gentilesco, MD FACP FHM2, 1The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI; 2Department of Medicine, The Miriam Hospital, Brown University, Providence, RI

Meeting: Hospital Medicine 2018; April 8-11; Orlando, Fla.

Abstract number: 880

Categories: Adult, Clinical Vignettes, Uncategorized

Case Presentation: A healthy 33-year-old woman presented with bilateral facial palsy for one week. Three weeks prior to presentation, she developed fevers, headache, diffuse myalgias, and distal limb paresthesias. One week prior to admission, she developed a right-sided facial droop. At that time she was diagnosed with Bell’s palsy secondary to a viral infection; Lyme serologies were negative. Within several days, the facial droop progressed, involving the left side of her face, and the patient presented to the hospital. Physical examination revealed mild tachycardia with otherwise normal vital signs. Neurologic examination was significant for bilateral facial paralysis with intermittent left cheek fasciculations and areflexia of the bilateral lower extremities. Her cranial nerves, sensation, and muscle strength were otherwise intact. The remainder of the examination demonstrated no further focal findings including rashes, synovitis, or abdominal tenderness.
Initial laboratory workup revealed normal serum chemistries and blood counts with mildly elevated transaminases, with AST 72 IU/ml and ALT 112 IU/ml. Blood parasite smear was negative. A non-contrast CT brain was normal. Lumbar puncture demonstrated albuminocytologic dissociation with protein elevated to 103 mg/dl and 3 nucleated cells. CSF HSV, VZV, and West Nile antibodies were negative. MRI brain showed bilateral cranial nerve VII enhancement. The patient was treated with 5 days of IVIG and by time of discharge had improved strength in her left facial muscles. She was initially treated empirically with acyclovir and ceftriaxone, which were later discontinued once testing returned negative. After discharge, Anaplasma IgM titers were found to be elevated to 1:320 and the patient was started on a 10-day course of doxycycline.

Discussion: Isolated bilateral facial paralysis and distal limb paresthesias without muscle weakness is an uncommon presentation of Guillain-Barré syndrome. It has been described as a syndrome that is distinct from the Miller-Fisher variant, which is characterized by ophthalmoplegia, ataxia, and areflexia, and may also be associated with the onset of bilateral facial weakness. Anaplasmosis has never been described as a cause of Guillain-Barré. It is well known to cause fevers, myalgias, leukopenia, and elevated transaminases; the CSF typically demonstrates a lymphocytic pleocytosis. Interestingly, anaplasmosis has also rarely been described to cause postinfectious complications involving the peripheral nervous system; brachial plexopathies and demyelinating polyneuropathy with facial numbness, ataxia, and extremity weakness have been described.

Conclusions: This case highlights an atypical presentation of Guillain-Barré syndrome, which can manifest as isolated bilateral facial palsy without limb weakness. Though our patient’s presenting symptoms were unusual, and despite living in an endemic area for tick-borne illnesses, her areflexia and CSF studies were classic for Guillain-Barré.

To cite this abstract:

Takahashi, A; Gentilesco, B. A CASE OF BILATERAL FACIAL PALSY. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 880. https://www.shmabstracts.com/abstract/a-case-of-bilateral-facial-palsy/. Accessed April 5, 2020.

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