Ascending paralysis, seizure and reduced consciousness

A 67-year-old man reported progressive numbness and weakness in both legs. The numbness had started in the right buttock 4 weeks before, progressing down the posterio-medial leg to the lateral foot, and evolving into a painful, burning sensation. He developed similar symptoms in the left leg 1 week later, with urinary hesitancy. Over the following 3 weeks, he started dragging the right foot and walking unsteadily. He had no back pain, preceding trauma, viral illness, systemic or craniobulbar symptoms, and no weakness or sensory symptoms in his arms or trunk. He had hypertension and diabetes and took irbesartan and metformin.

On examination, his mental status, cranial nerves and upper limbs were normal. Lower limb tone was normal with no atrophy, spasticity or clonus. There was asymmetric distal weakness in right ankle dorsiflexion (2/5), inversion (4/5), eversion (3/5) and left ankle dorsiflexion (4+/5). Lower limb reflexes were absent other than the right…

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