2025 – PAGE 397 – NEUROLOGY

ACUTE FLACCID MYELITIS (AFM)

Acute flaccid myelitis (AFM) is uncommon and causes weakness and decreased reflexes. Cases have been increasing since 2014. Most cases occur in young children, with cases in children ranging from 3 months to 21 years, but with a median age of 6. Symptoms include hypotonia, hyporeflexia, difficulty moving eyes or droopy eyelids, facial droop or weakness, difficulty with speech or swallowing, pain in the arms and legs, and pain in the neck or back. Severe cases can result in respiratory failure and instability of body temperature and blood pressure. The etiology is uncertain but thought to be enterovirus D68. Diagnosis requires an MRI showing a spinal cord lesion primarily in the gray matter and CSF with pleocytosis. Additional body fluids are tested in search of viral etiologies. Treatment is supportive along with rehab including PT and OT.

(DOUBLE TAKE) TICK PARALYSIS

Tick paralysis can present with a child who has a clinical picture very similar to that of Guillain-Barre Syndrome (GBS). That means you’re looking for an acute ascending paralysis in which there are absent reflexes. It will likely be preceded by ataxia. It’s caused by a neurotoxin produced by ticks, and the solution is to remove the tick!

PEARL: If you are presented with a child who seems to have Guillain-Barre Syndrome (GBS), but they mention a trip, the woods, or the summertime, they are probably talking about this! Other KEY differentiating factors include the lack of fever, normal CSF, and a quicker progression of symptoms (hours – 2 days). Other confusing choices may be Botulism (DESCENDING paralysis) or PoliomyeLITIS (+CSF findings and possible viral syndrome).

NAME ALERT:  This is not TODD PARALYSIS.

(DOUBLE TAKE) TODD PARALYSIS (AKA TODD’S PARALYSIS)

If a child presents with focal motor weakness after a seizure, pick TODD PARALYSIS (AKA Todd’s Paralysis)!

PEARL: There is often NO HISTORY of a witnessed seizure, so have a high index of suspicion for this diagnosis in any child presenting with an acute onset of unilateral weakness of an extremity.

NAME ALERT:  This is not TICK PARALYSIS.

TRANSVERSE MYELITIS

Transverse myelitis is an inflammation of the spinal cord and can look very much like a cord compression syndrome (bowel/bladder dysfunction and increased reflexes). It may or may not be related to a chronic inflammatory condition. Look for a history of fever and back pain. These patients can die of respiratory compromise. CSF from a lumbar puncture may show neutrophils. Diagnose by noting a swollen and inflamed cross section (across the entire/transverse section) of spinal cord on an MRI.