Reversible Man‐in‐the‐Barrel Syndrome from Septic Shock

1University of Missouri–Kansas City School of Medicine, Kansas City, MO
2Virginia Tech–Carilion School of Medicine, Roaonke, VA

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 275

Case Presentation:

A 66‐year‐old woman presented with pneumonia, severe sepsis, acute respiratory failure requiring mechanical ventilation, acute kidney injury, and disseminated intravascular coagulation. Her medical history included diabetes and hypertension. Her temperature was 103.9°F, blood pressure 111/42 mm Hg, weight 125 kg, BMI 42. On examination she was mechanically ventilated and sedated, with unremarkable cardiopulmonary findings. She moved all extremities, and deep tendon reflexes were I/ IV throughout. She was pancytopenic, with platelets 11,000/μL, lactate dehydrogenase 3560 IU/L (91–180 IU/ L), undetectable haptoglobin, and fibrinogen 113 mg/dL (155–450 mg/dL). She received cefepime, ciprofloxacin, and vancomycin. Hypotension and anuria ensued, requiring pressors and dialysis. Endotracheal extubation seemed appropriate by day 7, but she remained encephalopathic. Furthermore, head, neck, and feet movement were intact, but both arms became completely paretic and areflexic. She grimaced to painful stimuli but could not move her arms. Head CT was unremarkable; the electroencephalogram showed mild, nonspecific cerebral disturbance. Brain MRI could not be completed given her body habitus. Dialysis ceased on day 28, decannulation was achieved on day 30, and she was discharged to rehabilitation on day 36, alert, oriented, and standing independently with functional use of both arms.


Sage and Van Uitert coined “man‐in‐the‐barrel” syndrome (MIBS) in 1986 to describe the characteristic pattern of disproportionate arm weakness with relative sparing of strength in the head, neck, and legs, as if one were enclosed by a barrel. MIBS generally occurs in the setting of profound systemic hypotension with resulting cerebral hypoperfusion in the watershed area between the anterior and middle cerebral arteries.


As this case illustrates, the hospitalist should consider MIBS with debilitated intensive care patients. Mimickers include critical‐illness polyneuropathy or myopathy, but the distinctive pattern of MIBS and a focused examination can often exclude these considerations.


V. Faridani ‐ none; C. Roi Garcia ‐ none; J. Sweet ‐ none

To cite this abstract:

Faridani V, Garcia C, Sweet J. Reversible Man‐in‐the‐Barrel Syndrome from Septic Shock. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 275. Journal of Hospital Medicine. 2011; 6 (suppl 2). Accessed March 31, 2020.

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