Bradycardia and asystole requiring permanent pacemaker in Guillain-Barré syndrome

Use of pacemaker in GBS dysautonomia

Autonomic dysfunction in Guillain-Barrè syndrome (GBS) involves labile hypotension, hypertension, resting tachycardia and sweating. While autonomic involvement affects 66% of patients with GBS, the changes are usually transient and reversible. We hereby delineate a case of a female who presented to our medical centre with flaccid, painless progressive quadriparesis with features of dysautonomia. She had resting tachycardia, was tachypneic with reduced chest expansion and required immediate invasive mechanical ventilation. After pertinent laboratory evaluation, nerve conduction studies were promptly performed at the bedside and findings were concordant with acquired acute inflammatory demyelinating polyneuropathy. The diagnosis of GBS was made on the standard set of investigations and plasmapheresis was initiated on the same day. Her intensive care unit stay was complicated by the multiple episodes of asystole. Even though a temporary transvenous pacemaker was inserted, she, unfortunately, succumbed to a sudden episode of asystole. This paper illustrates that GBS-associated autonomic dysfunction can be severe and close cardiac monitoring is imperative in these patients.

Safety and Clinical Outcomes of an Equine-derived Heptavalent Botulinum Antitoxin Treatment for Confirmed or Suspected Botulism in the United States

BACKGROUND

Botulism is a rare, life-threatening paralytic illness. Botulism Antitoxin Heptavalent (A,B,C,D,E,F,G)-(Equine) (BAT) manufactured by Emergent BioSolutions Canada Inc is an equine-derived heptavalent botulinum antitoxin product indicated for the treatment of symptomatic botulism following documented or suspected exposure to botulinum neurotoxin serotypes A-G in adults and pediatric patients. BAT product was US-licensed in 2013.

METHODS

In the United States, from October 2014 through July 2017, safety and clinical outcomes data were collected under a registry for patients treated with BAT product.

RESULTS

Registry patients had a median age of 51 years (range, 32 days to 92 years). Among 162 patients, 7 (4.3%) experienced BAT product-related serious adverse events, including 1 (0.6%) report each of pneumonia, pneumonia aspiration, ventricular tachycardia, upper gastrointestinal hemorrhage, anaphylactic reaction, acute kidney injury, and acute myocardial infarction. Thirty-one (19.1%) patients had 41 BAT product-related adverse events. Six (3.7%) deaths were reported in the registry. All deaths were attributed to the underlying illness and were assessed as unlikely related to BAT product. Among 113 (69.8%) patients with a final diagnosis of botulism, those treated early (≤2 days) spent fewer days in the hospital (5 vs 15.5 days), in the intensive care unit (ICU) (4 vs 12 days), and on mechanical ventilation (6 vs 14.5 days) than those treated late (>2 days), respectively.

CONCLUSIONS

BAT product was well tolerated in patients. Treatment with BAT product at ≤2 days of symptom onset was associated with shorter hospital and ICU stays, and shorter duration and need for mechanical ventilation, showing clinical benefit associated with early treatment.

Immune mediated diseases and immune modulation in the neurocritical care unit

This chapter will review the spectrum of immune-mediated diseases that affect the nervous system and may result in an admission to the neurological intensive care unit. Immunomodulatory strategies to treat acute exacerbations of neurological diseases caused by aberrant immune responses are discussed, but strategies for long-term immunosuppression are not presented. The recommendations for therapeutic intervention are based on a synthesis of the literature, and include recommendations by the Cochrane Collaborative, the American Academy of Neurology, and other key organizations. References from recent publications are provided for the disorders and therapies in which randomized clinical trials and large evidenced-based reviews do not exist. The chapter concludes with a brief review of the mechanisms of action, dosing, and side effects of commonly used immunosuppressive strategies in the neurocritical care unit.

Long-term transvenous temporary pacing with active fixation bipolar lead in the management of severe autonomic dysfunction in Miller-Fisher syndrome: A case report

Management of severe autonomic dysfunction in patients with Guillain-Barre syndrome (GBS) or its variant Miller-Fisher syndrome (MFS) include placement of permanent pacemaker. We report a case of MFS with severe bradycardia and asystole treated initially with an external permanent (temporary-permanent) pacemaker with a transvenous, active fixation right ventricular lead placement as a "bridge" to permanent pacing.

[Cardiac involvement in neuromuscular diseases]

Many neuromuscular disorders involve the heart, occasionally with overt clinical disease. Muscular dystrophies (dystrophinopathies, limb girdle muscular dystrophy, Emery-Dreifuss muscular dystrophy, Steinert's myotonic dystrophy), congenital myopathies, inflammatory myopathies and metabolic diseases (glycogenosis, periodic paralysis, mitochondrial diseases) may produce dilated or hypertrophic cardiomyopathy and heart rhythm or conduction disturbances. Furthermore the heart is commonly involved in some hereditary and degenerative diseases (Friedreich's ataxia and Kugelberg-Welander syndrome) and acquired (Guillain-Barré syndrome) or inherited (Refsum's disease and Charcot-Marie-Tooth syndrome) polyneuropathies. A cardiologist's high clinical suspicion and a simple but systematic skeletal muscle and peripheral nerve investigation, including muscle enzymes quantification, neurophysiological study and muscle biopsy, are necessary for an accurate diagnosis. In selected patients, more sophisticated biochemical and genetic analysis will be necessary. In most cases, endomyocardial biopsy is not essential for the diagnosis.

Guillain-Barré syndrome

The leading cause of acute neuromuscular weakness in the developed world is Guillain-Barré syndrome (GBS). Mortality rates vary widely. This article discusses the care and management of patients with GBS, with an emphasis on those patients who require admission to an intensive care unit.

Autonomic involvement in Guillain-Barré syndrome: a review

Autonomic neuropathy is an important and common complication of Guillain-Barré syndrome (GBS). Manifestations be present in cardiovascular, sudomotor, gastrointestinal and other systems involving both sympathetic and parasympathetic fibers. Some apparently selective acute autonomic neuropathies may be subvarieties of GBS. Experimental work in animal models, pathological studies of GBS patients, and autonomic function studies have provided some help in the understanding of this complication. In managing GBS patients with autonomic dysfunction there are important practical considerations that can improve their care. In this article we review the literature on autonomic neuropathy in GBS and propose a management scheme to accommodate it in the overall treatment of the neuropathy.

[Dysautonomia at 2 times in Guillain-Barré syndrome]

Autonomic dysfunction is described in a 63 year old woman suffering from Guillain-Barré syndrome. Bradyarrhythmias occurred during the convalescent phase, whereas neurologic and respiratory symptoms were improving; they were not related to bronchial aspiration. Their severity and the inefficiency of medical treatment led to the insertion of a demand pace-maker. Cardiac monitoring by the Holter method in severe cases of Guillain-Barré syndrome may detect potentially lethal arrhythmias, that may then be avoided by a demand pace-maker.