Journal of Emergencies, Trauma, and Shock
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LETTERS TO EDITOR  
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 163-164
A case of tetraplegia after Proteus mirabilis infection


Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka, Japan

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Date of Submission20-May-2017
Date of Acceptance20-Jun-2017
Date of Web Publication8-Aug-2017
 

How to cite this article:
Jitsuiki K, Ishikawa K, Omori K K, Yanagawa Y. A case of tetraplegia after Proteus mirabilis infection. J Emerg Trauma Shock 2017;10:163-4

How to cite this URL:
Jitsuiki K, Ishikawa K, Omori K K, Yanagawa Y. A case of tetraplegia after Proteus mirabilis infection. J Emerg Trauma Shock [serial online] 2017 [cited 2019 Sep 18];10:163-4. Available from: http://www.onlinejets.org/text.asp?2017/10/3/163/212502


Dear Editor,

A 74-year-old male patient was found unconscious in the prone position in his house. The patient had hypertension and right thalamic hemorrhage but was capable of living independently. After his arrival in the emergency room, he manifested a shock state with unconsciousness and underwent a massive infusion of lactate ringer solution, a continuous infusion of noradrenaline, as well as mechanical ventilation after tracheal intubation without the use of muscle relaxants or steroids. When a catheter was inserted into his bladder, cloudy urine was observed. He was diagnosed with a urinary tract infection treated by an intermittent infusion of levofloxacin, dehydration, septic shock, acute respiratory distress syndrome, and renal failure. The patient's urine and blood were positive for Proteus mirabilis. His general condition improved with the administration of these treatments and he was extubated on the 7th hospital day. After extubation, flaccid tetraplegia was observed without cranial nerve palsy. Urgent cervical magnetic resonance imaging did not reveal any significant lesions. Electromyography and a nerve conduction study revealed the decreased amplitude of multiple nerves without any conduction velocity abnormality. The patient was negative for antiganglioside antibodies. Four months after admission, the patient obtained a full recovery from tetraplegia and was discharged on foot.

This is the first report of a patient with tetraplegia after P. mirabilis infection. Critically ill patients with polyneuropathy and myopathy usually present with flaccid and symmetric paralysis, which is seen in approximately 25%–45% of critically ill patients who are admitted to intensive care units.[1],[2] Acute respiratory distress syndrome, sepsis (especially in patients with Gram-negative bacteremia), systemic inflammatory response syndrome, and multiple organ failure, prolonged bed rest, medication, and hyperglycemia, are major risk factors for critical illness polyneuropathy and myopathy.[1],[2] Human studies have identified axonal degeneration in critical illness polyneuropathy and myosin loss in critical illness myopathy.[1],[2] Sepsis-related disturbances of the microcirculation in the peripheral nerves and muscles, and the resultant production of cytokines, may increase the permeability of the microvasculature and further exacerbate hypoxemia and energy depletion, following the axonal degeneration of the sensory and motor axons in critical illness polyneuropathy.[3] As the present case also had Gram-negative bacteremia with multiple organ failure, and showed muscle action potential amplitudes of <80% of the normal lower limit in two or more nerves without conduction block, critical illness polyneuropathy was the most likely cause of his tetraplegia. Early rehabilitation that combines mobilization with physiotherapy is emerging as an important strategy for treating critical illness polyneuropathy and myopathy, and for facilitating and improving their long-term recovery.[2] Accordingly, the present case underwent rehabilitation using passive and spontaneous training and a favorable functional outcome was obtained.

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Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Callaghan BC, Price RS, Feldman EL. Distal symmetric polyneuropathy: A review. JAMA 2015;314:2172-81.  Back to cited text no. 1
[PUBMED]    
2.
Zhou C, Wu L, Ni F, Ji W, Wu J, Zhang H. Critical illness polyneuropathy and myopathy: A systematic review. Neural Regen Res 2014;9:101-10.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Fenzi F, Latronico N, Refatti N, Rizzuto N. Enhanced expression of E-selectin on the vascular endothelium of peripheral nerve in critically ill patients with neuromuscular disorders. Acta Neuropathol 2003;106:75-82.  Back to cited text no. 3
[PUBMED]    

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Correspondence Address:
Youichi Yanagawa
Department of Acute Critical Care Medicine, Shizuoka Hospital, Juntendo University, Shizuoka
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_4_17

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