Reversible tetraplegia after percutaneous nephrostolithotomy and septic shock: a case of critical illness polyneuropathy and myopathy with acute onset and complete recovery

Abstract

Background: Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are complications causing weakness of respiratory and limb muscles in critically ill patients. As an important differential diagnosis of Guillain-Barré syndrome (GBS), CIP and CIM should be diagnosed with caution, after a complete clinical and laboratory examination. Although not uncommon in ICU, CIP and CIM as severe complications of percutaneous nephrostolithotomy (PNL) have not been documented in literature.

Case presentation: A 48-year-old Chinese woman was referred to our hospital, complaining of occasional pain in the right lower back for one month. Lithiasis was diagnosed by ultrasonographical and radiological examinations on the urinary system. PNL was indicated and performed. The patient developed CIP and CIM on the fourth day after PNL. Early recognition and treatment of the severe complications contributed to a satisfactory recovery of the patient.

Conclusion: This case expands our understanding of the complications of PNL and underscores the importance of differentiating CIP/CIM from GBS in case of such patients developing weakness after the treatment. Clinical characteristics and examination results should be carefully evaluated to make the diagnosis of CIP or CIM. Both anti-septic prophylaxis and control of hyperglycemia might be effective for the prevention of CIP or CIM; aggressive treatment on sepsis and multiple organ failure is considered to be the most effective measure to reduce the incidence of CIP/CIM.

Figure 1

Imaging manifestations of lithiasis. Radiological evaluation was performed with IVU following a KUB. A. KUB before the intravenous injection of contrast. B. KUB 30s after the intravenous injection of contrast. A 2.5 cm × 1.0 cm high-density mass was shown in the right ureter at the L3 level (A and B, black arrows). Right renal pelvis was enlarged (B, red arrow). Lithiasis was diagnosed on the basis of the imaging features after excluding other diseases.

Figure 2

Therapeutic strategies for CIP and CIM. No specific therapy has been proved to be beneficial to manage CIP or CIM. Supportive measures including nutritional interventions, anti-oxidant therapies, hormone replacement, and immunoglobulins have been proposed. Intensive insulin therapy remarkably improves blood glucose control, and independently reduces the incidence of CIP/CIM. Early rehabilitation combining mobilization with physiotherapy is also advisable.