The Unfeeling Refugee

Clinical Presentation: Progressive Paraparesis

A 26-year-old West African man presented with a week-long history of progressive lower-extremity weakness and urinary retention. Initially, he noticed problems trying to rise from a chair without using his arms, and then upon awakening, he was unable to get out of bed. He also has been unable to urinate and has no sensation in his legs. All of his muscles became involved at once, along with an "electrical tingling" below his umbilicus. He has no other complaints.

History and Physical Examination

History. History revealed the following:

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  Medical history: none
  
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  Medications: none
  
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  Allergies: none
  
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  Habits: none
  
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  Pets: none
  
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  Diet: regular
  
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  Travel: has been in the United States for 6 months; a political refugee from West Africa. No unusual childhood infections.
  
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  Social: married, student, has a 1-year-old child. Grew up in rural Africa.
  
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  Immunizations: had bacille Calmette-Guérin (BCG) as a child; purified protein derivative (PPD)-negative on arrival to the United States
  
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  Sports/water exposure: none
  
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  Infectious disease exposure: had all vaccine-preventable diseases as a child
  

Physical examination. The following were noted:

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  Vital signs: temperature, afebrile; pulse, 80 beats/min; respiratory rate, 20 breaths/min; blood pressure, 150/90 mm Hg
  
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  HEENT: normal
  
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  Lungs: clear
  
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  Heart: normal
  
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  Abdomen: normal
  
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  Extremities: normal
  
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  Skin: multiple scars from previous torture
  
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  Genitourinary: normal
  
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  Neurologic: no sensation or motor function from the umbilicus down.
  

Diagnostic Evaluation

Laboratory results. The following values were obtained:

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  WBC count: 12,000 cells/µL
  
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  Hemoglobin level: 10.4 g/dL
  
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  Differential: normal
  
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  Bilirubin level: 0.9 mg/dL
  
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  Aminotransferase levels: normal
  
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  Urinalysis: normal
  
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  HIV: positive on enzyme-linked immunosorbent assay (ELISA)
  
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  Lumbar puncture:
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    Cerebrospinal fluid (CSF): thick, yellow, Karo syrup consistency
    
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    WBC: 240,000 cells/µL, with 95% monocytes
    
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    Protein: not measurable (> 3 g, upper limit of assay)
    
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    Glucose: 25 mg/dL
    
  
  

Imaging

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  Chest radiography: no pathology
  
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  CT of head: normal
  
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  MRI of spine: diffuse thickening and inflammation of the lower thoracic and lumbar spinal cord
  

Questions answered incorrectly will be highlighted.

What is this patient's diagnosis?

Polio

West Nile virus

Guillain-Barré syndrome

Tuberculosis

African sleeping sickness