Renal, hepatic and thyroid functions were normal. activities of daily living. She experienced a medical history of main squamous cell carcinoma of the tongue that experienced recurred postresection, a postirradiation gingival sarcoma and a mandibular spindle cell (sarcomatoid) squamous cell carcinoma. There was no history of alcohol misuse or a significant family history. On examination, she was alert and orientated with a sinus tachycardia of 120?bpm and oxygen saturations of 82% on room air flow. Her conjunctivae were pale. Respiratory, abdominal and cardiovascular examinations DMOG were unremarkable. Neurological examination revealed a weakness of all limbs, corresponding to Medical Research Council grade 4/5 in all ranges of movement. No fasciculations were noted. Cerebellar and cranial nerve indicators were absent. Light touch sensation was absent to the knees bilaterally with pain sensation absent to the level of mid-tibia bilaterally. DMOG These signs were symmetrical. There was decreased light touch and pain sensation of both hands. There were absent deep tendon reflexes in the legs and both plantars were downgoing. Reflexes in the arms were brisk. In the following fortnight, her neurological symptoms worsened with ascending paraesthesia to the waist and decreasing power in the lower limbs. The areflexia progressed to involve all reflexes in the upper limbs where there was also progressive sensory loss to the elbows, but with retained power. The working diagnosis was Guillain-Barr syndrome (GBS) secondary to a para-neoplastic process. The patient was too unwell to travel to the neurological unit for nerve conduction studies. DMOG Serial vital capacity measurements were undertaken twice daily and reduced over time. Investigations The patient experienced a normocytic anaemia (9.7?g/dl), thrombocytosis (753109/l) and a neutrophilia (neutrophil count of 11.1109/l). Renal, hepatic and thyroid functions were normal. In addition laboratory assessments including antinuclear antibody, serology for HIV, cytomegalovirus and Borrelia and urinalysis (including 5-hydroxyindoleacetic-acid and catecholamines) proved negative. Cerebrospinal fluid (CSF) analysis 5?days postadmission showed no significant cellularity, normal plasma:CSF glucose ratio, no organisms on Gram staining, but a raised protein of 506.7?mg/l. Owing to the lack of a clear focus of pathology, a whole body positron emission tomography scan was performed that showed multifocal intense flurorodeoxyglucose uptake within numerous bones (physique 1) and the right lobe of the thyroid. Ultrasound scan of the thyroid showed a heterogeneous appearance with no suitable nodules for fine needle aspiration. A left sacral alar biopsy (physique 2) was obtained under CT guidance. This showed metastatic poorly differentiated squamous cell carcinoma with some spindle/sarcomatous differentiation and areas of signet-ring-like morphology (physique 3). This was judged likely to be a metastatic recurrence of the previous neoplastic lesion in the patient’s mandible given the comparable histology. Open in a separate window Physique?1 Total body fluorodeoxyglucose (FDG) positron emission tomography scan showing multifocal intense FDG uptake in numerous bones, in particular involving the cervical and thoracic spine, the left sacral alar and left femur. Open in a separate window Physique?2 Superimposed axial CT fluorodeoxyglucose (FDG) positron emission tomography scan of pelvis intense FDG uptake in the left sacral alar. Open in a separate window Physique?3 Histology slide of left sacral alar. Immunolabelled with AE1AE3 a cytokeratin marker. Serum screening for antiganglioside antibodies was initially unfavorable, but on day 5 of admission it became strongly positive with a titre of 1 1 in 3200 (0C200 normal range) by day 13. Investigations for antineuronal antibodies were negative. MRI imaging of the brain and spine was unremarkable. Treatment There were no curative or palliative chemotherapy or radiotherapy options for this patient and therefore the priority was symptom control. A course of intravenous immunoglobulins at 2?g/kg was started for 5?days, but this resulted in no neurological improvement. End result and follow-up She died on day 34 of her admission from respiratory arrest. Conversation Here, we present a case of a lady who developed paraneoplastic GBS secondary to a disseminated squamous cell carcinoma. The clinical features of an acute ascending areflexic paralysis with sensory involvement and albuminocytogenic dissociation of DMOG CSF fill the Brighton Collaboration criteria for the diagnosis of GBS1 and the presence of antiganglioside antibodies further strengthens the diagnosis and indicates an axonal subtype.2 While it cannot be ruled out that this GBS Ccna2 was secondary to a preceding infective process, the absence of infective symptoms and negative antibodies to and.