Corticosteroids for Guillain-Barré syndrome

Analysis of Clinical Symptoms of Guillain–Barré Syndrome Induced by Heat Stroke: Three Case Reports and Literature Review

Background

Heat stroke is a potentially fatal condition that is caused by elevated core temperature. Guillain–Barré syndrome (GBS) induced by heat stroke is extremely rare and has only been reported in few case reports. The purpose of this case study was to evaluate the clinical symptoms, neuroelectrophysiological and imageological features of GBS after heat stroke.

Methods

We reviewed our hospital records and previously published reports to find the cases of GBS after heat stroke. The clinical, imageological, and electrophysiological profiles, treatment and prognosis were presented and analyzed.

Results

We retrieved three cases of GBS induced by heat stroke from our hospital, which presented as lesions on multiple cranial and peripheral nerves and albuminocytologic dissociation in the cerebrospinal fluid. All of these patients had disorders of consciousness at the early stage of heat stroke and a “pseudo-recovery period” after they recovered from coma after heat stroke. After immunoglobulin administration and immunoregulation therapy, these patients' neurological deficiencies were relieved significantly. But there are still disabilities and almost totally reliant on others.

Conclusions

The number of the cases of GBS induced by HS reported in this study has been the most in the recent 5 years. Clinicians should pay attention to patients with heat stroke with sustained coma and the sudden quadriplegia. Early, exact and timely diagnosis and treatment of GBS need to be performed, to accelerate recovery and improve prognosis.

Guillain-Barré Syndrome Following an Extended-Spectrum Beta-Lactamase Escherichia coli Urinary Tract Infection: A Case Report

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that typically develops after a respiratory or gastrointestinal infection. While Campylobacter jejuni is associated with approximately 30% of cases, organisms such as Haemophilus influenzae, Mycoplasma pneumonia, Epstein-Barr virus, cytomegalovirus, Zika virus, influenza virus, and hepatitis A, B, C, and E have demonstrated clinical associations to GBS. In rare instances, Escherichia coli infections have been documented as the underlying cause for GBS. Our patient, a 69-year-old female, was admitted with a two-week history of progressively worsening bilateral lower extremity weakness following diagnosis of an extended-spectrum beta-lactamase E. coli urinary tract infection. She was diagnosed with GBS based on acute flaccid paralysis, areflexia, and a nerve conduction velocity study showing an absent motor response in her lower extremities bilaterally. The patient subsequently underwent intravenous immunoglobulin (IVIG) treatment for five days which resulted in significant improvement in her bilateral lower extremity weakness, a response consistent with the diagnosis of GBS.

Guillain Barre Syndrome: A Single Center Experience

Objectives:

To investigate the clinical, electrophysiological and epidemiological features of the patients who were diagnosed as Guillain Barre Syndrome (GBS) in our clinic.

Methods:

The clinical and demographical properties of 30 patients with GBS who were hospitalized in our neurology clinic between March 2013 and August 2017 were retrospectively examined in this study. Patients were divided into two groups according to the requirement of stay in the intensive care unit (ICU).

Results:

Patients were between 18-71 years range with 46.9 and 19.61 mean age. Seven of 30 patients (23.3%) were female, and 23 of them (76.7%) were male. Males were more dominant in the ICU (-) group (81% and 62%). A recent infection was found in 86.7% of patients. Upper respiratory tract infection (URTI) was more common in ICU (+) group whereas lower respiratory tract infection (LRTI) and acute gastroenteritis (AGE) were more common in the ICU (-) patients (p=0.007). Lower limb weakness was more frequent in the ICU (+) group (p=0.011). ICU (+) patients were lack of diplopia and dysarthria. Ataxia and dysphagia were relatively frequent in the ICU (+) group. Electrophysiological examinations revealed demyelinating polyneuropathy (26.7%), acute axonal polyneuropathy (30.1%) and acute sensorial polyneuropathy (13.3%). Demyelinating polyneuropathy was more common in the ICU (-) group, whereas acute motor and sensorial polyneuropathy (AMSAN) was more frequent in the ICU (+) group. In this study, 26.7 % of study patients required mechanical ventilation, and mortality rate was 6.8 %.

Conclusion:

URTI in ICU (+), LRTI and AGE in ICU (-) patients might be major trigger factors of GBS. Ascending weakness, dysphagia and ataxia was more frequent in ICU (+) GBS patients. Demyelinating PNP was predominant in the ICU (-) group, whereas AMSAN was more frequent in the ICU (+) patients. Multicenter randomized studies would be more useful for highlining the epidemiology of GBS.

Guillain-Barré Syndrome and Its Variants: Clinical Course and Prognostic Factors

Introduction

We aimed to analyze the frequency, clinical characteristics, medical treatment options and final functional status of Guillain-Barré syndrome (GBS) and its variants in a population from a tertiary hospital setting.

Methods

All medical records of patients with acute inflammatory polyneuropathy between the years of 1998-2013 were retrospectively screened. Demographic, clinical and laboratory information, treatment options and the rate of recovery of the patients were gathered.

Results

A total of 183 patients met the study criteria. Subtypes were typical demyelinating form (n=102, 79.1%), acute motor sensory axonal variant (n=11, 8.5%), acute motor axonal variant (n=10, 7.8%), Miller-Fisher syndrome (n=5, 3.9%), and pure sensory subtype (n=1, 0.8%). Remaining patients had the diagnosis of acute-onset chronic inflammatory demyelinating polynuropathy. The data of treatment option were available for 70 patients. Most of the patients received intravenous immunoglobulin (IVIg) treatment or the combination of IVIg and methylprednisolone. One patient died, there was no improvement in eight patients and rest showed improvement with varying degrees.

Conclusions

We did not observe major change of recovery between different treatment options, however, most of the patients using methylprednisolone required IVIg because of inadequate response.

Fulminant Guillain-Barré syndrome in a patient with systemic lupus erythematosus

A 45-year-old man with a history of systemic lupus erythematosus presented with progressive weakness and areflexia. Electromyogram revealed reduced motor and sensory amplitudes without demyelinating features. He was clinically diagnosed with the acute motor and sensory axonal neuropathy variant of Guillain-Barré syndrome. Despite intravenous immunoglobulin therapy, he deteriorated with loss of all voluntary motor function and cranial nerve reflexes. Concomitant investigations revealed class V lupus nephritis. Therapy was initiated with plasma exchange, glucocorticoids and further immunosuppression, with gradual neurological recovery. We present the first documented case of fulminant Guillain-Barré syndrome as a neuropsychiatric manifestation of systemic lupus erythematosus, highlighting how immune-mediated polyneuropathy via diffuse deafferentation may mimic the outward appearance of brain death. While glucocorticoids are not indicated in idiopathic Guillain-Barré, when this neurological disorder is a consequence of systemic lupus erythematosus, immunomodulatory treatment should be initiated to prevent neurological deterioration.

Diagnosis and Treatment of Lower Motor Neuron Disease in Australian Dogs and Cats

Diseases presenting with lower motor neuron (LMN) signs are frequently seen in small animal veterinary practice in Australia. In addition to the most common causes of LMN disease seen world-wide, such as idiopathic polyradiculoneuritis and myasthenia gravis, there are several conditions presenting with LMN signs that are peculiar to the continent of Australia. These include snake envenomation by tiger (Notechis spp.), brown (Pseudonaja spp.), and black snakes (Pseudechis spp.), tick paralysis associated with Ixodes holocyclus and Ixodes coronatus, and tetrodotoxins from marine animals such as puffer fish (Tetraodontidae spp.) and blue-ring octopus (Hapalochlaena spp.). The wide range of differential diagnoses along with the number of etiological-specific treatments (e.g., antivenin, acetylcholinesterase inhibitors) and highly variable prognoses underscores the importance of a complete physical exam and comprehensive history to aid in rapid and accurate diagnosis of LMN disease in Australian dogs and cats. The purpose of this review is to discuss diagnosis and treatment of LMN diseases seen in dogs and cats in Australia.

Emergency Neurological Life Support: Acute Non-traumatic Weakness

Acute non-traumatic weakness may be life-threatening if it involves the respiratory muscles and/or is associated with autonomic dysfunction. Most patients presenting with acute muscle weakness have a worsening neurological disorder that requires a rapid, systematic evaluation and detailed neurological exam to localize the disorder. Urgent laboratory tests and neuroimaging are needed to confirm the diagnosis. Because acute weakness is a common presenting sign of neurological emergencies, it was chosen as an Emergency Neurological Life Support protocol. Causes of acute non-traumatic weakness are discussed here by both presenting clinical signs and anatomical location. For each diagnosis, key features of the history, examination, investigations, and treatment are outlined in the included tables or in the "Appendix".

Corticosteroids for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute paralysing disease caused by inflammation of the peripheral nerves, which corticosteroids would be expected to benefit.

OBJECTIVES

To examine the ability of corticosteroids to hasten recovery and reduce the long-term morbidity from GBS.

SEARCH METHODS

On 12 January 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We also searched trials registries.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs of any form of corticosteroid or adrenocorticotrophic hormone versus placebo or supportive care alone in GBS. Our primary outcome was change in disability grade on a seven-point scale after four weeks. Secondary outcomes included time from randomisation until recovery of unaided walking, time from randomisation until discontinuation of ventilation (for those ventilated), death, death or disability (inability to walk without aid) after 12 months, relapse, and adverse events.

DATA COLLECTION AND ANALYSIS

The review authors used standard methods expected by Cochrane.

MAIN RESULTS

The review authors discovered no new trials in the new searches in June 2009, November 2011, or January 2016. Six trials with 587 participants provided data for the primary outcome. According to moderate quality evidence, the disability grade change after four weeks in the corticosteroid groups was not significantly different from that in the control groups, mean difference (MD) 0.36 less improvement (95% confidence intervals (CI) 0.16 more to 0.88 less improvement). In four trials of oral corticosteroids with 120 participants in total, there was very low quality evidence of less improvement after four weeks with corticosteroids than without corticosteroids, MD 0.82 disability grades less improvement (95% CI 0.17 to 1.47 grades less). In two trials with a combined total of 467 participants, there was moderate quality evidence of no significant difference of a disability grade more improvement after four weeks with intravenous corticosteroids (MD 0.17, 95% CI -0.06 to 0.39). According to moderate quality evidence, there was also no significant difference between the corticosteroid treated and control groups for improvement by one or more grades after four weeks (risk ratio (RR) 1.08, 95% CI 0.93 to 1.24) or for death or disability after one year (RR 1.51, 95% CI 0.91 to 2.5). We found high quality evidence that the occurrence of diabetes was more common (RR 2.21, 95% CI 1.19 to 4.12) and hypertension less common (RR 0.15, 95% CI 0.05 to 0.41) in the corticosteroid-treated participants.

AUTHORS' CONCLUSIONS

According to moderate quality evidence, corticosteroids given alone do not significantly hasten recovery from GBS or affect the long-term outcome. According to very low quality evidence, oral corticosteroids delay recovery. Diabetes requiring insulin was more common and hypertension less common with corticosteroids based on high quality evidence.

The devil is in the detail: Acute Guillain-Barré syndrome camouflaged as neurosarcoidosis in a critically ill patient admitted to an Intensive Care Unit

Guillain–Barré syndrome (GBS) is an acute demyelinating polyneuropathy, usually evoked by antecedent infection. Sarcoidosis is a multisystem chronic granulomatous disorder with neurological involvement occurring in a minority. We present a case of a 43-year-old Caucasian man who presented with acute ascending polyradiculoneuropathy with a recent diagnosis of pulmonary sarcoidosis. The absence of acute flaccid paralysis excluded a clinical diagnosis of GBS in the first instance. Subsequently, a rapid onset of proximal weakness with multi-organ failure led to the diagnosis of GBS, which necessitated intravenous immunoglobulin and plasmapheresis to which the patient responded adequately, and he was subsequently discharged home. Neurosarcoidosis often masquerades as other disorders, leading to a diagnostic dilemma; also, the occurrence of a GBS-like clinical phenotype secondary to neurosarcoidosis may make diagnosing coexisting GBS a therapeutic challenge. This article not only serves to exemplify the rare association of neurosarcoidosis with GBS but also highlights the need for a high index of clinical suspicion for GBS and accurate history taking in any patient who may present with rapidly progressing weakness to an Intensive Care Unit.

Immune-mediated neuropathy with Epstein-Barr virus-positive T-cell lymphoproliferative disease

A 47-year-old man with Epstein-Barr virus (EBV)-positive T/NK- cell lymphoproliferative disease (EBV-T/NK-LPD) developed acute-onset weakness. A nerve conduction study showed a conduction block in both the proximal and most distal segments. Although the patient's neuropathy transiently responded to intravenous immunoglobulin, it was progressive for at least 25 days until the start of prednisolone (PSL) administration, after which it remarkably improved. The neuropathy further improved after allogeneic bone marrow transplantation (BMT). The present patient's clinical course is not consistent with that of typical Guillain-Barré syndrome. This case suggests that EBV-T/NK-LPD can cause progressive immune-mediated neuropathy as a result of chronic EBV antigen presentation and can be treated with PSL and BMT.

Guillain-Barré syndrome associated with pulmonary tuberculosis

A 47-year-old male smoker admitted complaining of progressive bilateral lower-limb and upper-limb weakness, without any numbness. He also complained of productive cough and fever for the last 2 weeks before admission. There were no nasal symptoms, sore throat, night sweats, loss of appetite and weight, nor did he have any gastrointestinal symptoms.

Clinical and pharmacological aspects of inflammatory demyelinating diseases in childhood: an update

Inflammatory demyelinating diseases comprise a spectrum of disorders affecting the myelin of the central and peripheral nervous system. These diseases can usually be differentiated on the basis of clinical, radiological, laboratory and pathological findings.

Recent studies have contributed to current awareness that inflammatory demyelinating diseases are not restricted to the adult age group, but are more common in pediatric age than previously believed. Some of pediatric inflammatory demyelinating diseases carry an unfavorable long-term prognosis but appropriate treatments can improve the outcome. The possibility of physical and cognitive disability resulting from these diseases, highlights the urgent need for therapeutic strategies for neurorehabilitation, neuroregeneration, and neurorepair.

This review discusses characteristics of primary demyelinating diseases more frequently observed in childhood, focusing on epidemiology, clinical aspects and treatments.

Guillain-Barré syndrome: a review

Guillain-Barré syndrome is an autoimmune disease which is a common cause of acute neuromuscular paralysis and should be suspected in all patients with unexplained motor weakness. Specific management strategies are more effective if given early in the course of the disease.

The role of cytokines in Guillain-Barré syndrome

Cytokines play an important role in the pathogenesis of autoimmune diseases including Guillain-Barré syndrome (GBS) and its animal model experimental autoimmune neuritis (EAN). In this article, we reviewed the current knowledge of the role of cytokines such as TNF-α, IFN-γ, IL-1β, IL-6, IL-12, IL-18, IL-23, IL-17, IL-10, IL-4 and chemokines in GBS and EAN as unraveled by studies both in the clinic and the laboratory. However, these studies occasionally yield conflicting results, highlighting the complex role that cytokines play in the disease process. Efforts to modulate cytokine function in GBS and other autoimmune disease have shown efficiency indicating that cytokines are important therapeutic targets.

Transient immunosuppression: a bridge between infection and the atypical autoimmunity of Guillain-Barré syndrome?

Guillain-Barré syndrome (GBS) is an acute, usually monophasic, disorder of the peripheral nervous system that is assumed to be of immune-mediated pathogenesis. However, several clinical features and experimental findings of GBS are uncharacteristic for an immune-mediated disorder and set this condition apart from other disorders with a putative immune-mediated pathogenesis. These features include, among others, the monophasic nature of GBS, the lack of response to immunosuppressive (unlike immunomodulatory) therapy, the absence of a typical association with immunogenetic background and the inability to establish a valid and relevant animal model. We suggest a comprehensive hypothesis for the pathogenesis of GBS that is based on the assumption that the condition is due to a transient (or occasionally chronic) immune deficiency, as in most cases GBS follows an infection with pathogens known to induce immunosuppression. Such infections may be followed by breakdown of immune tolerance and induction of an immune attack on peripheral nerves. Mounting of the immune-mediated assault might be triggered either by the same infective pathogen or by secondary infection. Clearance of the infection and resumption of a normal immune response and tolerance eventually terminate the immune-mediated damage to the peripheral nerves and enable recovery. This hypothesis assumes that the entire sequence of events that culminates in GBS is due to transient exogenous factors and excludes a significant role for inherent host susceptibility, which explains the monophasic nature of the disorder.

Multidisciplinary care for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome is a significant cause of new long-term disability, which is thought to be amenable to multidisciplinary care, but the evidence base for its effectiveness is unclear.

OBJECTIVES

To assess the effectiveness of multidisciplinary care in adults with Guillain-Barré syndrome, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 2), MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), AMED (1985 to May 2010), PEDro (1982 to May 2010) and LILACS (1982 to May 2010). We checked the bibliographies of papers identified and contacted their authors and known experts in the field seeking published and unpublished trials.

SELECTION CRITERIA

Randomised and controlled clinical trials that compared multidisciplinary care in Guillain-Barré syndrome with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary care in different settings or at different levels of intensity.Studies of 'other designs' (such as observational studies) were included only in the Discussion since such studies could only be of limited contribution to the best evidence synthesis.

DATA COLLECTION AND ANALYSIS

We performed a 'best evidence' synthesis based on methodological quality.

MAIN RESULTS

No randomised controlled trials or controlled clinical trials were identified. We summarised the results of three observational studies in the Discussion section of this review.

AUTHORS' CONCLUSIONS

In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date comes from three 'very low quality' observational studies. These provide some support for improved disability in the short term (less than 6 months) with high intensity inpatient multidisciplinary rehabilitation; and for improved quality of life, as measured by a reduction in handicap (participation). These conclusions are tentative and the gap in current research should not be interpreted as proof that multidisciplinary care is ineffective. Further research is needed into appropriate study designs; outcome measurement; caregiver needs; and the evaluation of optimal settings, type, intensity or frequency and cost-effectiveness of multidisciplinary care in the Guillain-Barré syndrome population.

Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is currently divided into the two major subtypes: acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor axonal neuropathy (AMAN). This review highlights relevant recent publications, particularly on the pathophysiology of AMAN. Molecular mimicry of the bacterial lipo-oligosaccharide by the human gangliosides is now considered an important cause of AMAN. Gangliosides GM1, GM1b, GD1a, and GalNAc-GD1a expressed on the motor axolemma are likely to be the epitopes for antibodies in AMAN. At the nodes or paranodes, deposition of antiganglioside antibodies initially cause reversible conduction block followed by axonal degeneration. Electrodiagnostic findings support this process. Disruption of glycolipids, which are important to maintain ion channel clustering at the nodes and paranode, may impair nerve conduction. Genetic polymorphisms of Campylobacter jejuni determine the expression of the gangliosides on the bacterial wall. In contrast, target molecules in AIDP have not yet been identified. Meta-analyses show efficacy of plasmapheresis and immunoglobulin therapy, but not corticosteroids, in hastening recovery.

Treatment for Fisher syndrome, Bickerstaff's brainstem encephalitis and related disorders

BACKGROUND

Fisher syndrome is one of the regional variants of Guillain-Barré syndrome, characterised by impairment of eye movements (ophthalmoplegia), incoordination (ataxia) and loss of tendon reflexes (areflexia). It can occur in more limited forms, and may overlap with Guillain-Barré syndrome. A further variant is associated with upper motor neuron signs and disturbance of consciousness (Bickerstaff's brainstem encephalitis). All of these variants are associated with anti-GQ1b IgG antibodies. Intravenous immunoglobulin (IVIg) and plasma exchange are often used as treatments in this patient group. This review was undertaken to systematically assess any available randomised controlled data on acute immunomodulatory therapies in Fisher Syndrome or its variants.

OBJECTIVES

To provide the best available evidence from randomised controlled trials on the role of acute immunomodulatory therapy in the treatment of Fisher Syndrome and related disorders.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Trials register (March 2004), MEDLINE (from January 1966 to November 2004), EMBASE (from January 1980 to November 2004), CINAHL (from January 1982 to November 2004) and LILACS (from January 1982 to November 2004) for randomised controlled trials, quasi-randomised trials, historically controlled studies and trials with concurrent controls. We adapted this strategy to search MEDLINE from 1966 and EMBASE from 1980 for comparative cohort studies, case-control studies and case series.

SELECTION CRITERIA

All randomised and quasi-randomised controlled clinical trials (in which allocation was not random but was intended to be unbiased, e.g. alternate allocation, and non-randomised controlled studies were to have been selected. Since no such clinical trials were discovered, all retrospective case series containing five or more patients were assessed and summarised in the discussion section.

DATA COLLECTION AND ANALYSIS

All studies of Fisher Syndrome and its clinical variants were scrutinised for data on patients treated with any form of acute immunotherapy. Information on the outcome was then collated and summarised.

MAIN RESULTS

We found no randomised or non-randomised prospective controlled trials of immunotherapy in Fisher Syndrome or related disorders. We summarised the results of retrospective series containing five or more patients in the discussion section.

AUTHORS' CONCLUSIONS

There are no randomised controlled trials of immunomodulatory therapy in Fisher Syndrome or related disorders on which to base practice.