THE MORNING REPORT

The Best in FOAM Education

  • Jeremy Hardin, MD

An Approach to Guillain-Barre Syndrome

A 19 year old female with a past medical history of anxiety, depression, bulimia (resolved 5 years ago) presents with weakness. She states that her weakness began two days ago, starting with her feet and slowly ascending up her legs. Initially she noticed tingling in her feet in the morning followed by difficulty grasping a pen in class. It progressed to hand numbness, prompting the patient to seek care. She is accompanied by her mother who states that there has been a change in the patient’s voice and that she has been having difficulty walking. She had an upper respiratory infection 3 weeks ago treated with a Z-pack. She denies recent travel, hiking, tick bites, rash, vision changes, and dysphagia.

Physical Exam:

  • Afebrile with vital signs stable

  • Fluent speech with hoarse voice

  • CN2-12 intact. Able to sustain upward gaze. Bilateral dysmetria with finger to nose testing present

  • 4/5 upper extremity strength, 3/5 lower extremity strength

  • Absent biceps, triceps, brachioradialis, patellar, achilles reflexes

  • Normal tone, no atrophy

  • Severely ataxic, wide based gait

  • No ticks present on skin exam

Differential Diagnosis:

  • Lyme

  • Tick paralysis

  • Transverse Myelitis

  • Guillain-Barre

  • Myasthenia gravis

  • Botulism

ED Workup/Management:

  • LP, encephalitis and tick panel

  • Obtain NIF (-30, -38 post IVIG)

  • Start IVIG

Final Diagnosis:

  • Guillain-Barre

Plan:

  • Admit PICU

Follow Up/Clinical Course:

  • Admitted to PICU

  • IVIG daily x5 days

  • NIF increased to -60, never required intubation or supplemental oxygen

  • CSF unremarkable (Protein 18, WBC 1)

  • 11 days inpatient

  • 2 weeks outpatient rehab

History:

Discovered in 1916 by Drs Guillain, Barre, and Strohl who observed albuminocytological dissociation in two independent cases.

Pathophysiology:

2/3 of patients experience an infection in the month before onset (30% Campylobacter jejuni). Autoimmune destruction of Schwann cells causing demyelination of peripheral nerves and motor fibers.

Take Away #1

LP will show Albumin-cytological dissociation of CSF (protein >45, WBC <10). MRI may show enhancement of anterior spinal nerve roots.

Take Away #2

NIF has not been shown to be more effective than FVC, and is more uncomfortable.

Jeremy Hardin, MD is a current first year resident at Stony Brook Emergency Medicine.

Reference(s):

Edited by Bassam Zahid, MD


#neurology #infectiousdisease #guillainbarre #jeremy #hardin #jeremyhardin

Stony Brook
EMergency Medicine

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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