A9-year-oldpreviouslyhealthyFilipino-Americanboypresentedtoaperipheralhospitalwitha2-dayhistoryofsudden-onsetrightarmweaknessinthesettingofintermittentfeversfor1weekpriortopresentation.Overthe2dayspriortopresentation,helosttheabilitytowrite,grabanyobjects,ormakeafistwithhisrighthand,aswellastheabilitytolifthisrightarmtodresshimself.Motorexaminationoftherightarmrevealedlowtone,0/5strengthforwristextension,elbowflexion,andelbowextension,andminimalmovementofallrighthandinterosseiandlumbricals.Righttrapeziusstrengthwas5/5.Lowerextremitystrengthwas5/5bilaterally.Sensationtolighttouch,pinprick,positionsense,andvibrationwasintactintheaffectedlimb.Hedeniedarmpain,changeinsensation,recenttrauma,andbladderorboweldysfunction.Thepediatricneurologyteamwasconsultedandhewasadmittedtothepediatricwardattheperipheralhospitalforfurtherevaluation.
9岁菲律宾裔美国男童，既往体健，因突发右上肢无力2天，病前1周间断性发热，医院。就诊的2天前患者右手不能书写、不能抓取任何东西、不能握拳，不能抬臂穿衣。右臂运动检查肌张力低，右侧伸腕、屈肘、伸肘肌力0级，右手骨间肌、蚓状肌可轻微收缩。右侧斜方肌肌力5级，双下肢肌力5级。受累的右上肢轻触觉、针刺觉、位置觉、震动觉正常。第II-XII对颅神经查体未见异常。右上肢腱反射消失，左上肢腱反射正常。患者否认上肢疼痛、感觉异常，否认近期外伤史及膀胱、直肠功能障碍。儿科神经病学组会诊后，医院儿科病房进一步诊治。
Questionsforconsideration:
1.Whatarethepossibleetiologiesforthispatient’srightarmweakness?
2.Whatwouldbethenextstepinmanagementforthispatient?
思考问题：
1.患者右上肢无力的可能原因是什么？
2.患者下一步应如何治疗？
SECTION2第二部分Thedifferentialdiagnosisforsudden-onsetrightupperextremityweaknessincludeslesionsatvariouslevelsoflocalization:musclelesions(unlikely),neuromuscularjunctionabnormalitiessuchasmyastheniagravis(unlikely),plexuslesionssuchasbrachialplexitis,rootlesionssuchascervicalradiculopathyorpolyradiculopathy,spinalcordlesionssuchascervicalcordischemia,transversemyelitisormonomelicamyotrophy,andbrainstemorbrainlesionssuchasintracranialhemorrhageorischemia.Otherintracranialdiagnosessuchasintra-axialtumorandmeningiomaareimprobableduetothelowermotorneuronfindings.
突发右上肢无力病因的鉴别诊断包括不同定位水平的多种疾病，如：肌肉病变（本例可能性不大），神经肌肉接头病变如重症肌无力（本例可能性不大），神经丛病变如臂丛神经炎，根性病变如神经根型颈椎病、多发性神经根病，脊髓病变如颈髓缺血、横贯性脊髓炎或单肢肌肉萎缩，脑干、大脑病变如颅内出血或缺血。由于表现为下运动神经元受损，故其它颅内疾病诊断如神经轴内（脑实质内）肿瘤和脑膜瘤可排除。
MRIofthecervicalspineattimeofinitialpresentationshowedswellingofthecervicalcordatlevelsC3-C8withnocontrastenhancement(figure,A).Specifically,therewasedemaofboththecentralcordandanteriorhorncells(figure,B).MRIofthebrainandrightbrachialplexusatthistimewerewithinnormallimits.EMGandnerveconductionstudiesatinitialpresentationwereattemptedbutabortedduetopatientintolerance.Thepatientwastreatedwitha3-dayhigh-dosesteroidcoursefollowedbya5-dayIVimmunoglobulintreatmentcourseduringthishospitalization.Neithertreatmentcourseresultedinanyimprovementinthemotorexamination,whichwasconducteddailybytheperipheralhospital’sattendingpediatricneurologist.Thepatientwasdischargedhomeafter13daysandhestartedphysicalandoccupationaltherapyfortheaffectedlimb.RepeatMRIofthecervicalspine3monthslatershowed北京治疗白癜风好专科北京那里有好的白癜风医院
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