Hyperacute Guillain-Barré syndrome mimicking stroke: report of 3 cases: Guillain-Barré and stroke

Case report: Guillain-Barré syndrome following acute ischemic brainstem stroke

Guillain-Barré syndrome (GBS) is a heterogeneous disease, and it usually develops after an antecedent infection, while rare cases develop following a central nervous system disease. Given the indeterminacy of prodromal infection symptoms and the overlap of symptoms with other neurological disorders, a rigorous clinical and neurological examination in conjunction with history is necessary for early diagnosis and treatment of GBS. Here we present a rare case of GBS following acute ischemic stroke which was different from previous reports such as GBS following hemorrhagic stroke or head trauma. Moreover, intravenous immunoglobulin was effective in this patient after 6 months of follow-up despite the potential risk of thrombotic events.

Atypical Guillain-Barre Syndrome With a Sensory Level and Hyper-Acute Presentation: A Case Report

A 46-year-old man with a prior history of cervical spondylosis and myelopathy needing cervical spinal surgery three years back presented to the emergency department with acute onset areflexic flaccid weakness of both lower extremities, with a sensory level at T10. Magnetic resonance imaging studies (MRI) of the cervical, thoracic, and lumbar spine ruled out significant cord compression, spinal cord ischemia, spinal shock, or findings to suggest transverse myelitis. CSF analysis showed normal albumin and protein; however, with the features of paraplegia with flaccidity, areflexia, absence of bowel and bladder symptoms, and MRI ruling out other possibilities, a diagnosis of Guillain-Barre syndrome (GBS) was made. The patient was treated with intravenous immunoglobulin (IVIG) and showed a clinical response, with improvement in strength in both lower extremities. This case is rare and unique, as it exhibits atypical features for a GBS case, including a sensory level and hyper-acute presentation, with the onset of weakness to a nadir within an hour. This case highlights the importance of awareness of such atypical GBS presentations so that the diagnosis is not missed and is appropriately managed for favorable patient outcomes.

Case Report: Early-Onset Guillain-Barre Syndrome Mimicking Stroke

Introduction: Guillain-Barre syndrome (GBS) is an acute immune-mediated inflammatory demyelinating polyneuropathy characterized by symmetrical limb weakness and areflexia. GBS can have different clinical manifestations; hence, the initial symptoms are also varied. Here, we describe a rare case of GBS presenting as hemiparesis and cranial nerve palsy, which mimic brainstem stroke. Case Presentation: A 53-year-old man was admitted to the hospital with a 3-h history of left-arm weakness, glossolalia, and right eyelid droop. After admission, his condition suddenly worsened, with quadriplegia, bilateral peripheral facial palsy, bilateral ophthalmoplegia, and other neurological symptoms. Based on the findings from a neurological examination, MRI, cerebrospinal fluid analysis, and nerve conduction study, a diagnosis of GBS was made. He received intravenous immunoglobulin (0.4 kg/day) for 5 days. After 20 days of systematic therapy, his dysphagia, dyspnea, facial paralysis, ocular movement disorder, and leg weakness recovered almost completely, but his arms were still moderately impaired, with a power of 4/5. Fortunately, the patient recovered well without any sequelae after 2 years of follow-up. Conclusions: In patients with an atypical presentation, the diagnosis of GBS is often delayed. With this case report, we intend to highlight the fact that some symptoms mimicking stroke may be a feature of GBS at onset; close observation and timely diagnosis are crucial for clinicians. Neuroimaging is a valuable diagnostic tool in differentiating stroke from GBS.

Rate of progression of Guillain-Barré syndrome is not associated with the short-term outcome of the disease

INTRODUCTION

There are no many data on association between progression rate of Guillain-Barré syndrome (GBS) and disease outcome.

AIM

The aim of our study was to analyze short-term outcome of GBS in relation to the rate of disease progression.

METHODS

Our retrospective study included patients diagnosed with GBS in seven tertiary healthcare centers from 2009 to 2014. According to the rate of disease progression from onset of symptoms to the nadir, patients were divided in three groups: rapid-onset GBS (nadir reached in maximum 48 h), gradual-onset (nadir reached in three to 14 days), and slow-onset (nadir in 15 to 28 days). GBS disability scale (GDS) was used to assess functional disability at nadir and on discharge.

RESULTS

Among 380 patients included in the study, 24 (6.3%) patients had rapid-onset, 274 (72.1%) gradual-onset, and 82 (21.6%) slow-onset GBS. Time from the onset of the disease to the hospital admission was much shorter in faster-onset forms (3.0 ± 4.1 days in rapid-onset vs. 6.8 ± 9.5 days in gradual-onset and 21.0 ± 9.6 days in slow-onset GBS, p < 0.01). Preceding events were less commonly identified in slow-onset forms. Patients with rapid-onset GBS were more likely to have axonal variants (p < 0.05). All three groups of patients were treated in a similar way, and there were no differences in GDS score at nadir (p > 0.05) and on discharge (p > 0.05) and no differences in the duration of hospital stay.

CONCLUSION

Faster progression of GBS does not imply a poorer short-term functional outcome of the disease.

Clinical Heterogeneity of Guillain-Barré Syndrome in the Emergency Department: Impact on Clinical Outcome

Guillain-Barré syndrome (GBS) is mainly classified into acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor axonal neuropathy (AMAN). Although diagnosis of GBS requires progressive weakness and universal areflexia or hyporeflexia, cases of GBS with preserved or increased deep tendon reflexes (DTRs) have been increasingly recognized. We report three cases of GBS, presenting at a single unit in six months. Our first case presented with pure sensory symptoms. The second case had nonspecific generalized weakness, while the third presented with typical ascending weakness. One of our patients had preserved DTRs, while the other two had increased DTRs. Our two cases with hyperreflexia were found to have a preceding Campylobacter jejuni infection and anti-ganglioside antibodies, and their electrophysiological studies revealed AMAN. The other case had an AIDP. Only one case was offered a diagnosis and treatment from the first emergency department (ED) visit and had a better clinical outcome. Clinical diagnosis of GBS in the ED can be challenging. Delay in diagnosis of GBS in the ED is common due to cases with intact or increased DTRs, atypical pattern of weakness, or pure sensory symptoms. Emergency physicians should be aware of GBS clinical heterogeneity, because early diagnosis and treatment improve clinical outcome.