A middle aged man with acute onset quadriparesis: a diagnostic exercise.

Department of 50-year-old male farmer presented with the first episode of sudden onset weakness involving Medicine, Maulana A all four limbs simultaneously for the last 8 hours. There were no sensory symptoms. The Azad Medical College patient was a chronic smoker (two cigarettes/d) for the past 20 years. There was no family history of and Assoc LN Hospitals, similar episodes. His pulse rate was 88/min, blood pressure 150/90mm Hg and respiratory rate 20/ New Delhi, India min. General examination showed minimal bilateral pedal edema and grayish pigmentation over face, knuckles and palmar creases with no evidence of clubbing [Figures 1, 2]. Abnormal findings Correspondence: on the nervous system examination included flaccid quadriparesis (power grade 2/5 in proximal Nirmal Kumar, muscles and 3/5 in distal muscles of the upper and lower limbs) with deep tendon reflexes and [email protected] plantar reflexes being not elicitable.