Invictus Reviews

Some Questions on Bulbar Affecting conditions

• Mel Herbert

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Mel does some MCQs to highlight the diseases affecting bulbar muscles we have been covering the last few weeks.

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Speaker 1:

Hey people, over the Invicti, I want to do some questions and consolidate some of what we've been talking about in the last few weeks, some of those neurological conditions. So I want to do this in a slightly different way. So, as always, you can let me know how it works. So if you're not watching this, you might want to just sort of jump over to the YouTube channel, because I'm going to go through some questions and try and highlight some stuff. So here we go, let's do some questions together in this format and obviously give me your feedback, give me what you think.

Speaker 1:

So, 45-year-old woman presents with diplopia, ptosis, difficulty, swallowing, so bulb up right, which we've been talking about. Symptoms start at probably 24 hours after eating some home-canned vegetables. Okay, now let me tell you where I got these questions from. I got these from ChatGPT and I said make ABEM-level questions out of a number of chapters and let's compare and contrast some of these diseases. So that's where those are coming from and they're not exactly like they'll be on the exam. But it's all about learning the knowledge because you know you do peer to get a better sense of what's going to be on the actual exam itself. So home-canned vegetables, that's a big giveaway, right, and I'll go through these explanations in a second.

Speaker 1:

On exam she has dry mouth, sluggish pupillary reflexes, no rashes present, which is the following is most likely Myasthenia gravis, guillain-barre syndrome, botulism or multiple sclerosis. I'll give you a second to think about it. There's a couple of things in there that suggest what it is. But we know it's bulbar and we know that Guillain-Barre can be bulbar with the Mellifisher variant. We know that Myasthenia gravis can be bulbar. We know that botulism can be bulbar and multiple sclerosis we haven't talked about that. It's a foil. It can also be anything. But there's a couple of things in this stem that suggest what it is. And the answer is what do you think? Answer is botulism. Why is it botulism? So botulism frequently presents with that descending muscle paralysis. Classically, autonomic symptoms can occur as well, but those bulba symptoms, and so that's all suggested by it. But it's the canned food which is the giveaway, right? We know that the spores can get into the canned food, it can replicate. You eat the canned food, you get the spores into you or you get the toxin into you and you can develop this syndrome. So myasthenia gravis, ocular emolument, for sure. It tends to spare the, the pupillary muscles. Guillain-barre tends to be ascending, but it doesn't have to be because of that Miller-Fisher variant and multiple sclerosis is usually not associated with such an acute time source after consuming specific foods. So the food was the big giveaway there and I think it's a good thing to remember. So let's do another one. And it is 25 year thing to remember, so let's do another one. Whoa and um, it is 25 year old.

Speaker 1:

Presents to newman's apartment with progressive I'm just gonna move this up 25 year old presents with progressive diarrhea is the big progressive weakness. What do I say? Diarrhea, progressive weakness in both legs now affecting his trunk. He has a diarrheal illness about a week ago and on exam he has absentee tendon reflexes but no vulva involvement. So the key thing with this stem, obviously, is that it's ascending. And then again they throw in this little pearl which you may or may not get in real life of the diarrheal illness.

Speaker 1:

So which one is it Again, myocytic grubbers, guillain-barre, botulism or multiple sclerosis? This time the answer is going to be Guillain-Barre because it's ascending motor weakness and that is often associated with diarrheal neurosis and the classic one we heard was Campylobacter jejuni and they have loss of reflexes and so myasthenia gravis? Probably not. Botulism didn't start bulba multiple sclerosis. It's going to say the same things. It's a course that comes and goes. So I think you get the idea here. But is this consolidating the pearls? Is this consolidating your knowledge of the last few weeks? So is this another question?

Speaker 1:

60-year-old man, fluctuating double vision and difficulty swallowing Same again right Bulba symptoms at the end of each day. So there is the big thing. So this is getting worse at the end of the day. Go watch these things that they're dropping in these little polls. Okay, I get to what you're saying.

Speaker 1:

He states that the test is usually better in the morning but gradually progresses throughout the day. Neurological exam is otherwise normal. Pupillary reflexes are intact. Which one is the most likely? The fact that it's worse at the end of the day suggests that it is myasthenia gravis. So the answer is myasthenia gravis, fluctuating muscle weakness, typically worse at the end of the day and is associated with bulbous findings. So that is the key thing. The end of the day part. Let's do another one. Let's do a 35-year-old presents with two days of percussive difficulties following and blurry vision. Wait a minute, this is Bulber again. Physical exam reveals ptosis in a dry mouth and poorly reactive pupils. She denies any recent illness but admits eating homemade salsa that was canned several months ago. Well, this is sort of that same thing again.

Speaker 1:

Now, instead of asking what's the diagnosis, they're going to ask you to confirm the suspected diagnosis. So what do you think the diagnosis is? It's a bit of a giveaway because we're talking about the canned food, we're talking about the bulbous symptoms. So that's going to be botulism. So that's pretty easy. What do we want to do to detect botulism? What you can actually look for the serum toxin. So you're going to have normal imaging, but you're going to find the toxin. So that's what you're going to look for.

Speaker 1:

Now. What we talked about is that you're going to treat them before you get confirmation if you're concerned because it's a progressive disorder. It takes forever for them to get better and the sooner you can block those toxins the better. So if you can't get rapid access to the toxin screen, which can be hard, getting the toxin, anti-toxin to stop it. So that is the key thing there. But let's go through some of these other ones. Diagnosis of botulism is confirmed by getting some of that toxin, and that's cool.

Speaker 1:

The endophenion test is improvement suggests myasthenia gravis. So it didn't really go back there. Improved with endophenium was one of the answers. Elevated acetylcholinesterase receptor antibodies what does that come with? Myasthenia gravis and anti-GQ1 antibodies is pretty specific for myelofacial variant of GAMBAR8. All right, so let's do one more. I think we've got one more here 50-year-old brought to the emergency department with acute onset of worsening muscle weakness, cranial nerve palsies and possible respiratory compromise. Okay, bulbar muscle findings again. Now we're getting down to the respiratory compromise. That is very concerning.

Speaker 1:

Which of the following management is most accurate when differentiated between botulism, Gambare syndrome and myosinogravus and the ED? So administer Pfizer stigmine if you suspect that it's Gambare, which is not true, right, because for Gambare, what are you going to do? Gambare syndrome, ivig. Administer an IVIG if Gambare syndrome is suggested? Yes, we would do that.

Speaker 1:

Perform a lung puncture if botulism is suspected? No, we don't really do that. If you're worried about other things, you would, but you don't really need an LP to diagnose botulism. Administer botulism antitrust for a suspected myasthenic crisis? No, myasthenic crisis is myasthenia. So we don't get botulism talking.

Speaker 1:

So the answer is, of course, ivig for suspected Guillain-Barre syndrome. So again, you need to make the diagnosis and then what's the right treatment for that diagnosis? So let's go through again. Guillain-barre, ivig, myasthenia gravis you want to do an acetylcholine esterase inhibitor like Pfizer's Stigme A little bit controversial about whether to do that in the men's pub IVIG plasmapheresis if it's severe, botulism antitoxin and a lumbar puncture might be useful for Guillain-Barre syndrome where you get that Albumin cytologic dissociation. So the high protein and the lack of cells. Alright, so that was just a few questions in a format of trying to compare and contrast. We're going to do some of these more of these neurological conditions which I consider these foils. But I would really like feedback. Is this kind of thing going through these questions this way? Is it useful? 8. Ripped out.