It's actually pretty darned difficult to get bitten by a coral snake — only about 20 people manage it every year. (They're not aggressive at all, and as elapids have short, back-set fangs.) More importantly, an envenomed bite would have produced symptoms rapidly, with the crisis, if it came, happening within a few hours of the bite. (It would be respiratory failure.)

The symptoms don't fit black widow (acute pain at and near the bite site), nor the other venomous snakes present in Georgia (cottonmouth, copperhead, and various rattlesnakes, all of which have largely hemotoxic venoms and again wouldn't produce anything like this). It's also completely unlike brown recluse.

Georgia has a couple of scorpions but I don't believe their stings are considered medically serious, and again I think (having trouble confirming) that they would come with acute localized pain.

So if you're thinking bite or sting, I think ticks are pretty much what's left.

From CDC:
Doesn't fit much of anything we've got.Doesn't look like rabies. Which is good, because she's be dead.

LOL. Not that I'm a MD, but there are plenty of reputable sources (WHO, NIH, journals) for paralytic rabies, which presents something resembling this case, that say it accounts for 20-30% of cases. WP CDC.

Well, actually, this is the key. You go through her hair with a fine tooth comb and find an engorged tick embedded into her scalp. You carefully remove the little ****er and she progressively improves over the course of the day. Bingo!
The diagnosis is tick paralysis!

Excellent in that your diagnosis is in the differential. Also consider cerebellar ataxia which was mentioned earlier, and acute cord compression.


There are three kinds of rabies, as you alluded to.
Paralytic rabies does mimic guillan-barres syndrome. The way to tell the difference is that in paralytic rabies you will have fever, bladder dysfunction (like in cervical cord lesions). Also in rabies you get a curious symptom called percussion myoedema where after tapping on tissue you'll get a sort of mounding up where you tapped. You won't see that in GBS. The prognosis for rabies is obviously pretty poor.

Love this discussion. Good info.

So tick paralysis can cause the sensory symptoms? That's the reason I basically crossed it off from the start.

Also, House once had an episode with this as the diagnosis.

Yes, minor symptoms are possible (paresthesias) as well as some loss of vib sense afaik

Mmph, you looked harder than I did. That really was just about everything CDC had on symptoms.

It still looks like she'd already be dead if it were rabies, unless the paralytic form goes on a lot longer. But shows how much you should (not) trust single sources.

Oh, just looking at my posts from yesterday: I should have said only ~20 people/year manage to get bitten by coral snakes in the US.

Corals (three types — species or subspecies is a matter of debate) are present across much of the extreme south. In Georgia, they're only the southern part of the state from what I've read. Not relevant anyway because the symptoms are so far off, but ... well, there ya go.

A quick search on tick paralysis shows that removal of the tick usually fixes the problem within hours, so if we think that's it (or might be) we need to check thoroughly. The most common tick involved is the dog tick (also Rocky Mountain wood tick, but wrong part of the country). If that's the species involved, then the tick will be huge by now (a centimeter or more if fully engorged; note the picture in wiki shows an unengorged individual, and they're only a few millimeters), and a careful check should find it. (Note that it would be very strange for it not to have dropped off after several weeks, so this argues against it being this cause — I doubt it will be, so the Guillain-Barré avenue, about which I know nothing, looks more fruitful. But looking for ticks will take ten minutes max, and can't hurt.)

It could be others species too, many of which are smaller (e.g., deer tick, the one that most often carries Lyme), so check carefully. She may play barefoot so look between toes, but they are much more likely to embed under folds of clothes (or skin). Waistline best shot, and armpits, though you'd think we'd have seen that by now — that we haven't suggest that it would actually be in her hair. I've seen them behind ears, but anywhere in the hair is possible. (If she's blonde, my experience says this is even more likely. And no, I'm not kidding. American dog ticks like light-colored hair — I've never seen this written down but I know it to be true.)

If found, remove slowly and carefully ldo.


Edit: See below for lulz.

twas tick paralysis.. look up

.

Um, duh. My eyes skipped right by that.

Was she blonde?

more of a brunette

I lived on a 3 acre farmette that back up to a 10,000 acre wooded horse park in NJ and saw just about all the ticks I'll ever need to see. But I was not aware some of them produced neurotoxins in their salivary glands.

As a point of order, in the real case, once the tick was removed was the girl given tetracycline on the oft chance the tick that was exchanging bodily fluids with the girl for > 36 hours might have slipped some Rickettsials in with the neurotoxins?

In practice, how long do you think the this would have taken to get figured out? I have no idea how "zebra" this is, or if this is actually the "horse" for the presentation?

very nice!

A tick...never would've known that

Well like I said, there are only really 2 causes of ascending paralysis (and I guess rabies too), so if you can see that symptom, you have 2 things at the top of your list to rule in or out. But there are other distracting symptoms and the respiratory failure takes precedence over other things. I've never seen tick paralysis except on House, so it is possibly very easy to forget about it given its rarity. Tcc1, who presumably saw this actual case develop, could probably give a better answer, but I'm just filling in the silence for now.

Question - how do you deal with false symptoms from patients. I.e. I am not sure whether it was actually relevant or not, but the original "stomach flu" could have been completely unrelated to what the actual cause was and could have been just that, a stomach bug. How do you deal with that ingeneral?

She was not - rickettsial prophylaxis is not indicated, treatment is given only when the patient is symptomatic. It's not prevalent enough to make the side effects of doxycycline worth it.

Depends on how well you know your medicine.. or, how well you think you know. Tick paralysis was not on the original differential diagnosis - you can't come up with something you've never thought of. This case is a good example of not getting too much momentum with one particular diagnosis when the symptoms don't quite fit.

In this case, you can't really exclude GBS from the differential based on the history alone, so lab tests/physical exam are required. In general confounds like this may lead you down the wrong road and lead to mistakes. Some are avoidable with increased knowledge and better questioning of the patient, and some simply aren't.

Total elapsed time from being admitted to removing the tick?

2 days

I'd do what they did in Dirty Rotten Scoundrels.

Not sure what that means.

Anyway, this is probably the last one of these I'll be able to do for the next 4-5 months at least. Hopefully someone else will fill in if the mood strikes!

Thanks for them. I don't usually get to participate intelligently myself, but I know that many people get a lot of of them and they're a major asset for the forum and help for those who do participate.

^^^^ fo sho.. i lurked the whole thread and always excited to get some developments that I understand