A case of acute heart failure associated with Guillain-Barré syndrome

Takotsubo cardiomyopathy in Guillain-Barré syndrome

BACKGROUND AND PURPOSE

Takotsubo cardiomyopathy (TCM) is a serious autonomic complication of Guillain-Barré syndrome (GBS). However, the association between TCM and GBS has not been investigated in detail. We investigated the characteristics of GBS patients with TCM (GBS-TCM).

METHODS

Clinical features and anti-ganglioside antibody between the GBS-TCM patients and 62 classical GBS patients without TCM as control patients were compared.

RESULTS

Eight GBS-TCM patients were identified, in whom TCM was diagnosed at a mean of 6.5 [range 3-42] days after the onset of GBS. The age at onset of GBS was elder in the GBS-TCM patients than in the control GBS patients (76.5 [56-87] vs. 52 [20-88] years, p < 0.01). Notably, cranial nerve deficits, particularly in the lower cranial nerves, were observed in all GBS-TCM patients (100% vs. 41.9%, p < 0.01). Additionally, the GBS-TCM patients showed a higher GBS disability score at nadir (5 [4-5] vs. 4 [1-5], p < 0.01), and lower Medical Research Council sum scores at admission and nadir (37 [30-44] vs. 48 [12-60] at admission, p < 0.05, and 20 [12-44] vs. 40 [0-60] at nadir, p < 0.05, respectively). Mechanical ventilation was more frequently required in the GBS-TCM patients (62.5% vs. 11.3%, p < 0.01). Three GBS-TCM patients were positive for anti-ganglioside antibodies.

CONCLUSIONS

TCM occurred at a relatively early phase of GBS. The characteristics of GBS-TCM were the elder, lower cranial nerve involvements, severe limb weakness, and respiratory failure.

Reversible stress cardiomyopathy in Guillain-Barré syndrome: a case report

Background

Case Presentation

Conclusions

P-wave dispersion in patients with Guillain-Barré syndrome

Cardiac autonomic dysfunction assessed by the presence of arrhythmia, by the methods, such as heart rate variability or blood pressure variability, and by the electrocardiographic abnormalities is common in Guillain-Barré syndrome (GBS). The goal of present study was to analyze the P-wave dispersion (PWD), which is the non-invasive marker of atrial arrhythmia, in GBS patients and to compare those with healthy individuals. Thirty-five patients with GBS (mean age 53.6 ± 15.5 years) and 35 healthy controls (mean age 49.2 ± 14.1 years) were included to this study. Demographic and clinical information of the patients with GBS were assessed retrospectively. A 12-lead surface electrocardiogram was acquired from all participants. Minimum and maximum P-wave duration and PWD were measured in the patients with GBS and healthy controls. Maximum P-wave duration and PWD were significantly longer, and minimum P-wave duration was significantly lower in the patients with GBS rather than the control group (p = 0.037, p < 0.001, p = 0.007, respectively). GBS disability scores were positively correlated with the maximum P-wave duration (p = 0.015, r = 0.406) and PWD (p = 0.001, r = 0.525). We found that PWD was significantly prolonged in GBS patients compared with the controls. The increased PWD which is cheap, quick, non-invasive and feasible electrocardiographic marker may be related to increased risk for atrial fibrillation in patients with GBS.

Neurogenic stunned myocardium in subarachnoid hemorrhage

"Stunned myocardium," characterized by reversible left ventricular dysfunction, was first described via animal models using transient coronary artery occlusion. However, this phenomenon has also been noted with neurologic pathologies and collectively been labeled "neurogenic stunned myocardium" (NSM). Neurogenic stunned myocardium resulting from subarachnoid hemorrhage (SAH) is a challenging pathology due to its diagnostic uncertainty. Traditional diagnostic criteria for NSM after SAH focus on electrocardiographic and echocardiographic abnormalities and troponemia. However, tremendous heterogeneity still exists. Traditional pathophysiological mechanisms for NSM encompassed hypothalamic and myocardial perivascular lesions. More recently, research on pathophysiology has centered on myocardial microvascular dysfunction and genetic polymorphisms. Catecholamine surging as a mechanism has also gained attention with particular focus placed on the role of adrenergic blockade in both the prehospital and acute settings. Management remains largely supportive with case reports acknowledging the utility of inotropes such as dobutamine and milrinone and intra-aortic balloon pump when NSM is accompanied by cardiogenic shock. Neurogenic stunned myocardium that follows SAH can result in many complications such as arrhythmias, pulmonary edema, and prolonged intubation, which can negatively impact long-term recovery from SAH and increase morbidity and mortality. This necessitates the need to accurately diagnose and treat NSM.

Unexpected Rapid Improvement and Neurogenic Stunned Myocardium in a Patient With Acute Motor Axonal Neuropathy: A Case Report and Literature Review

Acute Motor Axonal Neuropathy-type Guillain-Barré Syndrome (GBS) is a subset of GBS with either a rapidly improving or protracted course that was first described in China. We describe a 27-year-old previously healthy woman with weakness that progressed to complete tetraplegia and areflexia within 2 weeks after an upper respiratory illness. A lumbar puncture performed 4 days after onset of neurologic symptoms was inconclusive for GBS, and electromyography revealed complete motor axonal neuropathy. The patient had Mycoplasma pneumoniae in her nares and blood, and several antiganglioside antibodies in her blood. She was treated with plasmapheresis, antibiotics, and physical therapy. Her motor function and reflexes improved rapidly with treatment, and she was able to ambulate within 3 weeks. She also experienced cardiomyopathy, which improved with plasmapheresis. We report a rare case of Mycoplasma pneumonia-associated acute motor axonal neuropathy-type GBS presenting with complete tetraplegia, areflexia, and neurogenic stunned myocardium that rapidly improved with plasmapheresis.

Coincidence of apical ballooning syndrome (tako-tsubo/stress cardiomyopathy) and posterior reversible encephalopathy syndrome: potential common substrate and pathophysiology?

BACKGROUND

Apical ballooning syndrome (ABS) and posterior reversible encephalopathy syndrome (PRES) are recently described, seemingly unrelated, reversible conditions. The precise pathophysiology of these syndromes remains unknown. The aim of this study was to describe the clinical characteristics and outcomes of a unique series of patients with both ABS and PRES.

METHODS AND RESULTS

In a retrospective study of 224 consecutive patients diagnosed with ABS between 2002 and 2010, 6 (2.7%) were also diagnosed with PRES. All were female with a mean age of 63.7 ± 12.5 years. All patients had preceding medical comorbidities and physical stress triggers that precipitated ABS and PRES. Mean peak troponin T levels and left ventricular ejection fraction at presentation were 0.47 ± 0.48 mg/dL and 31.5 ± 8.2%, respectively. Characteristic left ventricular wall motion abnormalities (regional wall motion score index 2.22 ± 0.37) were noted in all patients, and magnetic resonance imaging of the brain was significant for vasogenic edema, predominantly in the posterior circulation. All patients recovered left ventricular (ejection fraction at follow-up 60.2 ± 6.0%) and neurologic function with supportive management. Two patients had recurrence of ABS and 1 of PRES during follow-up.

CONCLUSIONS

ABS and PRES can occur simultaneously during an acute illness. Patients with ABS who develop neurologic dysfunction should be evaluated for PRES and vice versa. Because transient sympathetic overactivity and microvascular dysfunction have been observed in both reversible syndromes, we speculate that they may represent the shared pathophysiologic mechanism.

Neurogenic stunned myocardium after acute hydrocephalus

Neurogenic stunned myocardium (NSM) is a syndrome of cardiac stunning after a neurological insult. It is commonly observed after aneurysmal subarachnoid hemorrhage but is increasingly being reported after other neurological events. The underlying mechanism of NSM is believed to be a hypothalamic-mediated sympathetic surge causing weakened cardiac contractility and even direct cardiac myocyte damage. The authors report 2 cases of NSM in pediatric patients after acute hydrocephalus. Both patients experienced severe cardiac dysfunction in the acute phase but ultimately had a good neurological outcome and a full cardiac recovery. The identification, treatment, and outcome in 2 rare pediatric cases of NSM are discussed, and the history of the brain-cardiac connection is reviewed.