Case description

In December 2016, a 69-year-old man with a history of hypertension, hypercholesterolaemia and knee operations developed an erythematous pruritic rash on his trunk, cold shivers and swollen hands and feet with paraesthesias and numbness while on holiday in Curaçao. Eight days later he developed pain in his right leg and back, provoked by walking and stretching. This pain slowly increased over the next 5 weeks to the point that it became difficult to walk. He was admitted to the neurology ward of a regional hospital in The Netherlands, and neurological examination showed an antalgic gait, hypaesthesia of fingertips and feet and normal muscle strength and tendon reflexes. MRI of the cervical, thoracic and lumbar spine without gadolinium was normal. Eight days after admission he developed a progressive weakness of the legs starting in the right leg. Neurological examination showed a proximal and distal flaccid paraparesis with absent reflexes of the legs and normal reflexes of the arms. Cerebrospinal fluid (CSF) examination 3 days after admission showed a leucocyte count of 1/10 E6/L and a protein level of 620 mg/L. Electrolytes, liver and kidney function and inflammatory parameters were normal. Nerve conduction studies (NCS) 5 days after admission showed slightly prolonged distal motor latencies of the peroneal and tibial nerves, mildly prolonged F-wave latencies of the ulnar and tibial …