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Neurology India, Vol. 51, No. 2, April-June, 2003, pp. 293 Letter to Editor A case of acute flaccid paralysis as an unusual presentation of serum sickness S. Jain, G. Swami, A. Arya, B. Chowdhry Accepted on 11.02.2002. Code Number: ni03102 Sir, A 4-year-old boy presented with muscle and bone pain starting from both the lower limbs and later on affecting both the upper limbs. By the third day symmetrical weakness in an ascending fashion followed closely making the child unable to sit or stand. At the same time the child also developed painful swellings of both knees and ankle joints. There was a preceding history of non-specific febrile illness a week before, which was treated with cefadroxyl, promethazine, cetrizine. There was no history of local trauma, intramuscular injection or snakebite. The child did not receive any sera or vaccine before illness and was immunized for age. On examination, the child was conscious and vital parameters, mental status and cranial nerve examination were normal. There was flaccid paralysis of all limbs with absent deep tendon reflexes and indeterminate plantar response. There was involvement of trunk musculature with sparing of the diaphragm. Both knees and ankles were swollen, very painful and tender. Clinical features of scurvy were absent. On inquiry, we found a similar episode of ascending paralysis with arthritis after a non-specific illness and drug intake 2 years back. History revealed intake of cefadroxyl, ibuprofen, promethazine, etc. The child recovered fully in around two months and remained symptom-free till the present episode. Routine hematological examination was normal. The CSF showed increased proteins (120 mg %) and ten lymphocytes. Nerve conductions were markedly reduced. ANA and rheumatoid factor were negative. Serum C3, C4 done in the second week of illness (after ten days of steroid) were at the lower limits of the normal range. A diagnosis of serum sickness was considered. During the course in the hospital the arthritis responded to steroids and subsided completely by the second week. The paralysis also started responding and by the third week the child was able to sit and walk with support. Complete neurological recovery occurred at the follow-up after 6 months. Serum sickness-like illness can rarely manifest as the Guillain-Barre syndrome, one of its most serious complications.1 The diagnosis of serum sickness-like illness was considered secondary to drugs, mainly cephalosporins, given to our patient on both the occasions. Serum sickness is a type III hypersensitivity reaction caused by the deposition of circulating immune complexes due to the injection of heterologous or foreign protein or sera. REFERENCES 1. Sly R. Michael. Serum sickness. In: Nelson Waldo E, Behrman Richad E, Kliegman Robert M, Arvin Ann M, editors. Nelson's Textbook of Pediatrics, 15th edn.WB. Saunders Company; 1996. pp. 649-50. Copyright 2003 - Neurology India. Also available online at http://www.neurologyindia.com |
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