Acute polyneuritis cranialis with total external ophthalmoplegia and areflexia.

CASE-REPORT Mrs. S. C., aged forty-one gave birth to a female child on March 19, 1970. She had a manual removal of placenta without anaesthesia and the baby needed resuscitation. Ten days later, on March 29, 1970, she noticed dizziness and unsteadiness in the morning. She also noticed that her voice was low pitched and hoarse. When she ate her breakfast she could not swallow properly and fluids regurgitated through her nose. The following day she complained of double vision and also tingling and numbness in her hands and feet. Her voice became so hoarse that she was barely able to speak. During the next twenty-four hours there was further deterioration with progress of all the symptoms, but the double vision disappeared. On examination on 3rd April, 1970 she was found to be alert, fully orientated, her mental functions and special senses were normal. Although the pupils reacted briskly to light, there was complete loss of movement of the eyes in all directions with slight bilateral ptosis and the eyes were fixed in the forward-gaze position. Mild bilateral facial weakness was also present. The palatal arches did not move and the gag reflex was absent. She was unable to cough. There was no weakness of trunk or limb muscles. However, all the tendon reflexes were absent and the plantar responses were flexor. She had mild tenderness of the muscles of the upper arm. Sensation was normal and her gait was slightly ataxic. Investigations: A full blood count, serum electrolytes, a radiograph of chest and skull were normal; E.S.R. was high (57 mm. in first hour). A lumbar puncture showed clear cerebrospinal fluid (C.S.F.) under normal pressure. C.S.F. protein was high (Figure) with normal cells (less than 1 /c.mm.) and a slightly abnormal Lange's colloidal gold curve (0123321000). The Wasserman reaction in blood and C.S.F. was negative. Tests and culture of bacteria and viruses from throat, urine, faeces, blood or C.S.F. were negative. Progress and Treatment: Intravenous injection of 10 mg. edrophonium hydrochloride on two occasions did not improve the opthalmoplegia. A week after the onset of illness, paraesthesae, dysphonia and dysphagia began to improve. However mild bilateral facial weakness of lower motor neurone type progressed and became very marked in another four days; Bell's phenomenon became positive on both sides and she was unable to close her eyes properly. At this time the eye movements also began to improve. She was able to swallow fluilds without regurgitation through her nose and the tendon reflexes returned in the lower limbs. Thereafter all the signs gradually cleared up. A definite improvement of the facial weakness