Peculiarly progressive tetraplegia

A 50-year-old woman was brought to our emergency department as she could no longer walk, even to the bathroom. The weakness in her legs began 5 days earlier and was accompanied by diffuse muscle discomfort. She reported that her arms were weak as well. A physician had administered some ‘shots’ on the day prior to admission to alleviate a suspected neurological problem. A similar constellation of complaints had occurred 3 months earlier but apparently resolved without specific treatments. Five months earlier, she had been at another hospital with a urinary tract infection. At that time, a serum creatinine level of 176 μmol/L and a serum potassium level of 2.7 mmol/L were reported and supplemental oral potassium was recommended. The heart rate was 65 beats/min, blood pressure was 154/86 mmHg and the respiratory rate was 24 breaths/min. The patient was profoundly weak in both upper and lower extremities and could not stand. Breathing appeared shallow. The lungs were clear; there were no cardiac or abdominal findings. A neurologist observed depressed reflexes but could not discern a neurological disorder. The haemoglobin was 10.9 g/dL and haematocrit 31 vol%. Arterial blood gases disclosed PaO2 60, PaCO2 49 mmHg, pH 7.17 and HCO3 15 mmol/L. The sodium level was 139, chloride 122 and potassium 1.27 mmol/L. The creatinine level was 182 μmol/L. By test strip, the urine pH was found to be 6.0, proteinuria was 2+ and sediments revealed numerous erythrocytes and white blood cells without casts. The urine sodium was 70, potassium 24 and chloride 67 mmol/L.