Paralysis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Luke Rusowicz-Orazem, B.S.

Overview

Paralysis is the complete loss of muscle function for one or more muscle groups. Paralysis often includes loss of feeling in the affected area.

Pathophysiology

Paralysis is most often caused by damage to the nervous system or brain, especially the spinal cord. Partial paralysis can also occur in the REM stage of sleep.

Paralysis may be localized, or generalized, or it may follow a certain pattern. For example, localized paralysis occurs in Bell's palsy where one side of the face may be paralyzed due to inflammation of the facial nerve on that side. Patients with stroke may be weak throughout their body (global paralysis) or have hemiplegia (weakness on one side of the body) or other patterns of paralysis depending on the area of damage in the brain.

Other patterns of paralysis arise due to different lesions and their sequelae. For example, lower spinal cord damage from a severe back injury may result in paraplegia, while an injury higher up on the spinal cord, such as a neck injury, can cause quadriplegia. Patients with paraplegia or quadriplegia often use equipment such as a wheelchair or standing frame for mobility and to regain some independence.

Most paralyses caused by nervous system damage are constant in nature; however, there are forms of periodic paralysis, including sleep paralysis, which are caused by other factors.

Causes

Common Causes

Causes by Organ System

Cardiovascular Arachnoiditis, Arteriovenous malformation, Cerebrovascular accident, Hemorrhagic stroke, Ischemic stroke, Stroke
Chemical/Poisoning Amnesic shellfish poisoning, Apricot seed poisoning, Bird cherry seed poisoning, Bitter almond seed poisoning, Blue-ringed octopus poisoning, Bog rosemary poisoning, Bottlebrush buckeye poisoning, Brown snake poisoning, Buckeye poisoning, Bush lily poisoning, California buckeye poisoning, Carbamate insecticide poisoning, Cherry seed poisoning, China tree poisoning, Chokecherry seed poisoning, Clupeotoxism, Coastal leucothoe poisoning, Cobra poisoning, Conium maculatum, Corn lily poisoning, Curare, Delphinium poisoning, Dimethyl phthalate, Donepezil toxicity, Elapid poisoning, Everlasting pea poisoning, Fetterbush poisoning, Flax poisoning, Florida leucothoe poisoning, Golden chain tree poisoning, Grayanotoxin, Japanese andromeda poisoning, Jessamine poisoning, Lobelia poisoning, Marine toxins, Mayapple poisoning, Mercury poisoning, Monkshood poisoning, Monocrotophos, Mountain andromeda poisoning, Mountain laurel poisoning, Nicotiana tabacum, Organophosphate insecticide poisoning, Peach seed poisoning, Pernettya poisoning, Persian violet poisoning, Red buckeye poisoning, Rhodotoxin, Sea wasp poisoning, Sheep laurel poisoning, Staggerbush poisoning, Sweetshrub poisoning, Tacrine toxicity, Tambocor , Tetraodon poisoning, Trumpet flower poisoning, Wild cherry seed poisoning
Dental No underlying causes
Dermatologic Leprosy
Drug Side Effect Acetylandromedol, Amikacin sulfate, Andromedotoxin, Azinphos-methyl, Bromide, Cytisine, Flecainide , Flecatab , Iodixanol, Lobeline, Pergolide, Temodar , Temozolomide , Thiram
Ear Nose Throat No underlying causes
Endocrine Adrenal adenoma, Adrenal cancer, Adrenal gland hyperfunction, Adrenal incidentaloma, Adrenocortical carcinoma, Adrenoleukodystrophy, Hyperadrenalism, Primary hyperaldosteronism
Environmental Decompression sickness, Dysbarism
Gastroenterologic Functioning pancreatic endocrine tumor, Insulinoma, Metastatic insulinoma, Schistosomiasis japonica, Schistosomiasis mansoni, Zellweger syndrome
Genetic Cerebrotendinous xanthomatosis, Chediak-higashi syndrome, Chiari malformation, Congenital defects, Familial infantile metachromatic leukodystrophy , Gm2-gangliosidosis, Homocystinuria syndrome, Juvenile paget's disease, Pelizaeus-merzbacher disease, Porphyria, Refsum disease, Tay sachs disease
Hematologic Adrenoleukodystrophy, Classical hodgkin disease, Familial infantile metachromatic leukodystrophy , Hodgkin's disease, Intracranial hemorrhage, Lymphocyte depletion hodgkin's disease, Lymphocytic choriomeningitis, Metachromatic leukodystrophy, Mixed cellularity hodgkin's disease, Nodular sclerosing hodgkin's lymphoma, Potassium deficiency, Primary hyperaldosteronism, Subarachnoid hemorrhage, Subdural hematoma
Iatrogenic Post-vaccinial encephalitis
Infectious Disease Arbovirosis, Encephalitis, Fungal meningitis, Hendra virus, Japanese encephalitis, Leprosy, Lyme disease, Lymphocytic choriomeningitis, Marburg multiple sclerosis, Mareck's disease , Neurosyphilis , Poliomyelitis, Post-polio syndrome, Progressive multifocal leukoencephalopathy, Rabies, Schistosomiasis japonica, Schistosomiasis mansoni, Simian b virus infection, Syphilis, Tetanus, Tetranortriterpene, Tick-borne encephalitis, Transverse myelitis
Musculoskeletal/Orthopedic Alexander disease, Chronic inflammatory demyelinating polyneuropathy, Cutaneomeningospinal angiomatosis, Encephalomyelitis, Enterovirus antenatal infection, Juvenile paget's disease, Paget's disease of bone, Rib tumor, Spinal cord injury, Spinal muscular atrophy, Spinal tumor, Tetranortriterpene
Neurologic Acute disseminated encephalomyelitis, Acute fulminant multiple sclerosis, Adrenal cortex neoplasms, Adrenal gland hyperfunction, Alexander disease, Amnesic shellfish poisoning, Amyotrophic lateral sclerosis , Ataxic cerebral palsy, Autoimmune diseases of the nervous system, Balo's concentric sclerosis, Bell's palsy, Benign astrocytoma, Botulism, Brachial plexus injury, Calcification of basal ganglia , California encephalitis, Canavan disease, Cerebral cavernous malformations, Cerebral palsy, Cerebral sarcoma, Cerebrotendinous xanthomatosis, Cerebrovascular accident, Chiari malformation, Chronic inflammatory demyelinating polyneuropathy, Compartment syndrome, Congenital defects, Conversion disorder, Cutaneomeningospinal angiomatosis, Decompression sickness, Desmoplastic cerebral astrocytoma of infancy, Desmoplastic infantile ganglioma, Dyskinetic cerebral palsy, Encephalitis, Encephalomyelitis, Fowl paralyses, Friedreich’s ataxia, Gm2-gangliosidosis, Guillain-barre syndrome, Hereditary peripheral nervous disorder, Hydrocephalus, Intercostal neuralgia, Intracranial hemorrhage, Japanese encephalitis, Krabbe disease, Leptomeningitis, Lyme disease, Malignant astrocytoma, Marburg multiple sclerosis, Motor neurone disease, Movement disorders, Moyamoya syndrome, Multiple myeloma, Multiple sclerosis, Muscular dystrophy, Neuroblastoma, Neurofibromatosis, Neurosyphilis , Nyssen-van bogaert syndrome, Pelizaeus-merzbacher disease, Peripheral neuritis, Poliomyelitis, Post-polio syndrome, Post-vaccinial encephalitis, Progressive multifocal leukoencephalopathy, Rasmussen's encephalitis, Selected encephalitides, Sleep, Spastic cerebral palsy, Spina bifida, Subarachnoid hemorrhage, Subdural hematoma, Syringomyelia, Tay sachs disease, Tick-borne encephalitis, Transverse myelitis, Vanishing white matter leukodystrophy
Nutritional/Metabolic Potassium deficiency
Obstetric/Gynecologic Spina bifida
Oncologic Adrenal adenoma, Adrenal cancer, Adrenocortical carcinoma, Back tumor, Cerebral sarcoma, Desmoplastic cerebral astrocytoma of infancy, Desmoplastic infantile ganglioma, Extradural hematoma, Functioning pancreatic endocrine tumor, Hip cancer, Malignant astrocytoma, Mesothelioma, Metastatic insulinoma, Multiple myeloma, Neuroblastoma, Neurofibromatosis, Nodular sclerosing hodgkin's lymphoma, Rib tumor, Spinal tumor
Ophthalmologic Refsum disease
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary Asphyxia
Renal/Electrolyte Hypokalemia
Rheumatology/Immunology/Allergy Systemic lupus erythematosus
Sexual Syphilis
Trauma Broken neck, Electrical burns, Fractures, Pathological fracture, Spinal cord injury
Urologic Zellweger syndrome
Miscellaneous No underlying causes

Causes in Alphabetical Order


Differential diagnosis

Diseases History and Physical Diagnostic tests Other Findings
Motor Deficit Sensory deficit Cranial nerve Involvement Autonomic dysfunction Proximal/Distal/Generalized Ascending/Descending/Systemic Unilateral (UL)

or Bilateral (BL)

or

No Lateralization (NL)

Onset Lab or Imaging Findings Specific test
Adult Botulism + - + + Generalized Descending BL Sudden Toxin test Blood, Wound, or Stool culture Diplopia, Hyporeflexia, Hypotonia, possible respiratory paralysis
Infant Botulism + - + + Generalized Descending BL Sudden Toxin test Blood, Wound, or Stool culture Flaccid paralysis (Floppy baby syndrome), possible respiratory paralysis
Guillian-Barre syndrome[1] + - - - Generalized Ascending BL Insidious CSF: ↑Protein

↓Cells

Clinical & Lumbar Puncture Progressive ascending paralysis following infection, possible respiratory paralysis
Eaton Lambert syndrome[2] + - + + Generalized Systemic BL Intermittent EMG, repetitive nerve stimulation test (RNS) Voltage gated calcium channel (VGCC) antibody Diplopia, ptosis, improves with movement (as the day progresses)
Myasthenia gravis[3] + - + + Generalized Systemic BL Intermittent EMG, Edrophonium test Ach receptor antibody Diplopia, ptosis, worsening with movement (as the day progresses)
Electrolyte disturbance[4] + + - - Generalized Systemic BL Insidious Electrolyte panel ↓Ca++, ↓Mg++, ↓K+ Possible arrhythmia
Organophosphate toxicity[5] + + - + Generalized Ascending BL Sudden Clinical diagnosis: physical exam & history Clinical suspicion confirmed with RBC AchE activity History of exposure to insecticide or living in farming environment. with : Diarrhea, Urination, Miosis, Bradycardia, Lacrimation, Emesis, Salivation, Sweating
Tick paralysis (Dermacentor tick)[6] + - - - Generalized Ascending BL Insidious Clinical diagnosis: physical exam & history - History of outdoor activity in Northeastern United States. The tick is often still latched to the patient at presentation (often in head and neck area)
Tetrodotoxin poisoning[7] + - + + Generalized Systemic BL Sudden Clinical diagnosis: physical exam & dietary history - History of consumption of puffer fish species.
Stroke[8] +/- +/- +/- +/- Generalized Systemic UL Sudden MRI +ve for ischemia or hemorrhage MRI Sudden unilateral motor and sensory deficit in a patient with a history of atherosclerotic risk factors (diabetes, hypertension, smoking) or atrial fibrillation.
Poliomyelitis[9] + + + +/- Proximal > Distal Systemic BL or UL Sudden PCR of CSF Asymmetric paralysis following a flu-like syndrome.
Transverse myelitis[10] + + + + Proximal > Distal Systemic BL or UL Sudden MRI & Lumbar puncture MRI History of chronic viral or autoimmune disease (e.g. HIV)
Neurosyphilis[11][12] + + - +/- Generalized Systemic BL Insidious MRI & Lumbar puncture CSF VDRL-specifc

CSF FTA-Ab -sensitive[13]

History of unprotected sex or multiple sexual partners.

History of genital ulcer (chancre), diffuse maculopapular rash.

Muscular dystrophy[14] + - - - Proximal > Distal Systemic BL Insidious Genetic testing Muscle biopsy Progressive proximal lower limb weakness with calf pseudohypertrophy in early childhood. Gower sign positive.
Multiple sclerosis exacerbation[15] + + + + Generalized Systemic NL Sudden CSF IgG levels

(monoclonal)

Clinical assessment and MRI [16] Blurry vision, urinary incontinence, fatigue
Amyotrophic lateral sclerosis[17] + - - - Generalized Systemic BL Insidious Normal LP (to rule out DDx) MRI & LP Patient initially presents with upper motor neuron deficit (spasticity) followed by lower motor neuron deficit (flaccidity).
Inflammatory myopathy[18] + - - - Proximal > Distal Systemic UL or BL Insidious Elevated CK & Aldolase Muscle biopsy Progressive proximal muscle weakness in 3rd to 5th decade of life. With or without skin manifestations.

Related Chapters



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