A retrospective analysis of possible triggers of Guillain–Barre syndrome

Differentiating recurrent Guillain-Barre syndrome and acute-onset chronic inflammatory polyneuropathy: literature review

Guillain-Barre syndrome (GBS) is an acute-onset immune-mediated polyneuropathy characterized by ascending symmetrical muscle weakness, diminished reflexes, and sensory symptoms. While GBS typically follows a monophasic course, some patients experience treatment-related fluctuations or recurrences, posing diagnostic challenges in distinguishing GBS from acute-onset chronic inflammatory polyneuropathy (A-CIDP). A-CIDP, may present acutely, simulating GBS, with a nadir in less than 8 weeks, subsequently evolving into a chronic or relapsing course. The distinction between recurrent GBS and A-CIDP is crucial, as A-CIDP necessitates long-term immunosuppression. A PubMed search was conducted using the search terms 'recurrent Guillain Barre syndrome' and 'acute onset CIDP' focusing on studies in the English language, published between January 1, 2004 and April 30, 2023. Overlapping clinical features, particularly in the early stages, complicate differentiation between recurrent GBS and CIDP. Electrophysiological studies, ultrasonography, and immunological markers have been explored for discrimination; however, definitive criteria for differentiation remain elusive. Recent follow-up studies have further blurred the boundaries between recurrent GBS and A-CIDP, suggesting the persistence of underlying immune processes even in GBS patients without clinical deterioration. This emphasizes the necessity of reevaluating diagnostic criteria and treatment strategies. In conclusion, distinguishing recurrent GBS from A-CIDP remains an ongoing challenge. Existing evidence questions the categorization of recurrent GBS as a distinct entity, challenging its very existence. Continued research is necessary to refine diagnostic criteria and deepen our understanding of these conditions, ultimately advancing patient care. This review delves into the intricacies of recurrent GBS and A-CIDP differentiation and highlights the need for a reevaluation of the recurrent GBS concept.

Evaluating algorithms for identifying incident Guillain-Barré Syndrome in Medicare fee-for-service claims

Objective

Claims data can be leveraged to study rare diseases such as Guillain-Barré Syndrome (GBS), a neurological autoimmune condition. It is difficult to accurately measure and distinguish true cases of disease with claims without a validated algorithm. Our objective was to identify the best-performing algorithm for identifying incident GBS cases in Medicare fee-for-service claims data using chart reviews as the gold standard.

Study design and setting

This was a multi-center, single institution cohort study from 2015 to 2019 that used Medicare-linked electronic health record (EHR) data. We identified 211 patients with a GBS diagnosis code in any position of an inpatient or outpatient claim in Medicare that also had a record of GBS in their electronic medical record. We reported the positive predictive value (PPV = number of true GBS cases/total number of GBS cases identified by the algorithm) for each algorithm tested. We also tested algorithms using several prevalence assumptions for false negative GBS cases and calculated a ranked sum for each algorithm's performance.

Results

We found that 40 patients out of 211 had a true case of GBS. Algorithm 17, a GBS diagnosis in the primary position of an inpatient claim and a diagnostic procedure within 45 days of the inpatient admission date, had the highest PPV (PPV = 81.6%, 95% CI (69.3, 93.9). Across three prevalence assumptions, Algorithm 15, a GBS diagnosis in the primary position of an inpatient claim, was favored (PPV = 79.5%, 95% CI (67.6, 91.5).

Conclusions

Our findings demonstrate that patients with incident GBS can be accurately identified in Medicare claims with a chart-validated algorithm. Using large-scale administrative data to study GBS offers significant advantages over case reports and patient repositories with self-reported data, and may be a potential strategy for the study of other rare diseases.

Guillain-Barré syndrome after surgery: a literature review

Guillain-Barré syndrome (GBS) is a rare postoperative complication that is sometimes characterized by serious motor weakness and prolonged weaning from mechanical ventilation. Although the exact nature of the relationship between GBS and the surgical procedure is still unclear, there is a clear increased incidence of GBS in post-surgical patients compared to non-surgical patients. GBS after surgery is unique in several ways. The course of post-surgical GBS unfolds more rapidly than in other situations where GBS develops, the condition is often more severe, and respiratory muscles are more commonly involved. Prompt diagnosis and appropriate treatment are essential, and the condition can worsen if treated inappropriately. Postoperative sedation, intubation, and restraint use make the diagnosis of GBS difficult, as the onset of symptoms of weakness or numbness in those contexts are not obvious. GBS is often misdiagnosed, being attributed to other postoperative complications, and subsequently mishandled. The lack of relevant information further obscures the clinical picture. We sought to better understand post-surgical GBS by performing an analysis of the relevant literature, focusing on clearly documenting the clinical characteristics, diagnosis, and management of GBS that emerges following surgery. We underscore the importance of physicians being aware of the possibility of GBS after major surgery and of performing a variety of laboratory clinical investigations early on in suspected cases.

Locked in from fulminant GBS after lumbar spine surgery

Guillain-Barré syndrome (GBS) describes a neurological syndrome characterised by acute, areflexic paralysis, often preceded by an immune stimulating event such as infection or surgery. Spinal surgery as an inciting event is very uncommon with few reported cases. When paraparesis develops in close proximity of surgery, surgical complications should be considered, but if an asymptomatic clinical interval precedes a progressive ascending weakness this association weakens and may support an immunological mechanism. GBS after lumbar surgery is wholly unexpected and thus there are significant challenges in recognising and making the diagnosis. We report a case of fulminant GBS that progressed to loss of all motor function following elective lumbar spine surgery.

Guillain-Barré syndrome after percutaneous coronary intervention and transcatheter aortic valve implantation

Guillain-Barré syndrome (GBS) usually develops after preceding infection, but cardiac surgery can also occasionally cause GBS. Currently, cardiac catheterizations have already become common therapeutic options for heart diseases, but there have been no reports of GBS occurrence after that. Herein, we present a rare case in which GBS occurred following catheterization. An 85-year-old-man with sudden onset chest pain was rushed to our hospital and diagnosed with ST-elevated myocardial infarction. He underwent emergent percutaneous coronary intervention (PCI) to left anterior descending artery, but he still had exertional chest pain. Echocardiography revealed severe aortic stenosis (AS) and our heart team considered AS was the cause of symptom and decided to perform and transcatheter aortic valve implantation (TAVI), 11 days after the PCI. However, 5 days after the TAVI procedure, he presented with symmetrical muscular weakness of extremities. Cranial magnetic resonance imaging showed no significant lesion. Based on several signs including albuminocytologic dissociation in cerebrospinal fluid examination, demyelinating polyneuropathy in nerve conduction study, positive anti-ganglioside antibody, and the lack of preceding infection, he was diagnosed with GBS triggered by cardiac catheterizations. We administered high-dose intravenous immunoglobulin therapy and his motor strength gradually improved, finally discharged with full motor strength after 7 months rehabilitation.

Learning objective

•Cardiac surgery has been already reported as a non-infectious risk factor of Guillain-Barré syndrome (GBS) in previous literatures, and cardiac catheterization such as percutaneous coronary intervention and transcatheter aortic valve implantation, which were relatively less invasive procedure, may be a potential risk factor for GBS occurrence as well.•If a patient complains of progressive, symmetrical neurological symptoms after cardiac catheterization, GBS should be considered as the possible cause, and nerve conduction study and cerebrospinal fluid examination may be helpful for the diagnosis.

Hospital-diagnosed morbidities and recent surgery as risk factors for developing Guillain-Barré syndrome

BACKGROUND AND PURPOSE

This study was undertaken to determine the association of hospital-diagnosed morbidity and recent surgery with risk of subsequent Guillain-Barré syndrome (GBS) development.

METHODS

We conducted a nationwide population-based case-control study of all patients with first-time hospital-diagnosed GBS in Denmark between 2004 and 2016 and 10 age-, sex-, and index date-matched population controls per case. Hospital-diagnosed morbidities included in the Charlson Comorbidity Index were assessed as GBS risk factors up to 10 years prior to the GBS index date. Incident major surgery was assessed within 5 months prior.

RESULTS

In the 13-year study period, there were 1086 incident GBS cases, whom we compared with 10,747 matched controls. Any pre-existing hospital-diagnosed morbidity was observed in 27.5% of GBS cases and 20.0% of matched controls, yielding an overall matched odds ratio (OR) of 1.6 (95% confidence interval [CI] = 1.4-1.9). The strongest associations were found for leukemia, lymphoma, diabetes, liver disease, myocardial infarction, congestive heart failure, and cerebrovascular disease, with 1.6- to 4.6-fold increased risks of subsequent GBS. GBS risk was strongest for morbidities newly diagnosed during the past 5 months (OR = 4.1, 95% CI = 3.0-5.6). Surgical procedures within 5 months prior were observed in 10.6% of cases and 5.1% of controls, resulting in a GBS OR of 2.2 (95% CI = 1.8-2.7). Risk of developing GBS was highest during the first month following surgery (OR = 3.7, 95% CI = 2.6-5.2).

CONCLUSIONS

In this large nationwide study, individuals with hospital-diagnosed morbidity and recent surgery had a considerably increased risk of GBS.

Guillain-Barré Syndrome with Incomplete Oculomotor Nerve Palsy after Traumatic Brain Injury: Case Report and Literature Review

Guillain-Barré syndrome (GBS) is a severe peripheral neuroinflammatory demyelinating disease characterized by symmetrical progressive limb weakness, which can be accompanied by cranial nerve and sensory disturbances. There is usually a history of bacterial or viral infection prior to onset. GBS is rarely seen after traumatic brain injury (TBI). We report a case of a 66-year-old male patient who presented with dilated pupils, followed by respiratory failure and symmetrical quadriplegia during a conservative treatment for TBI. He was eventually diagnosed with GBS and was treated with intravenous immunoglobulin, followed by rehabilitation therapy with a good recovery. We summarize previous similar cases and analyze possible causes. It is suggested that the possibility of GBS should be considered when unexplained symptoms occurred in patients with TBI, such as respiratory failure, dilated pupils, and limb weakness.

Acute Onset of Guillain-Barré Syndrome after Multiple Spine Surgeries: A Rare Case Report

Guillain-Barré syndrome is an autoimmune disorder presented by ascending paralysis and areflexia. The condition has been reported after many infections, but Guillain-Barré syndrome after spine surgery is rare. We, herein, present a case of Guillain-Barré syndrome after multiple spine surgeries for degenerative lumbar scoliosis. A 60-year-old woman with degenerative scoliosis underwent surgery for the third time and developed Guillain-Barré syndrome 3 weeks after the final operation. The patient received intravenous immune globulin therapy and needed mechanical ventilation and intensive care. She was discharged in good condition after 5 weeks.

Case Report: Delayed Guillain-Barré syndrome following trauma: A case series and manage considerations

Aim

To analyze clinical associations between Guillain-Barré syndrome (GBS) and trauma.

Material and Methods

We retrospectively reviewed the data of eight patients with post-traumatic GBS between July 2011 and December 2018 at the Second Xiangya Hospital, China, and analyzed the triggers, clinical manifestation, examination results, treatment, prognosis, and potential mechanism related to post-traumatic GBS.

Results

The included patients had GBS preceded by no risk factors other than trauma. Their age ranged from 15 to 60 years (the median age was 52 years), and six patients were males. The potential traumatic triggers included spinal surgery (n = 2), high-intensity exercise (n = 2), traumatic brain injury (n = 1), excessive fatigue (n = 1), ischemic stroke (n = 1), and cardiopulmonary resuscitation (n = 1). The major manifestation was symmetrical limb weakness and/or numbness in all patients. The diagnosis of GBS was based on the results of electromyography, albumino-cytological dissociation, or antiganglioside antibody in cerebrospinal fluid, and other diseases were excluded. Immunotherapy improved symptoms, except in one patient who died.

Conclusions

Trauma is a probable risk factor for GBS that is very easily overlooked, thereby leading to misdiagnosis in clinical practice. We emphasize a new concept of post-traumatic GBS to promote doctors' awareness when they meet people with weakness and sensory deficits after trauma, which benefit early diagnosis, timely treatment, and reduced mortality rate of GBS.

Perioperative Bilateral Medial Medullary Infarction With "Snake Eyes Appearance": A Case Report

Perioperative bilateral medial medullary infarction (BMMI) cases mimicking acute motor axonal neuropathy (AMAN) under general anesthesia have not been reported. We describe a patient who suffered flaccid quadriplegia and could not wean from mechanical ventilation after emergence from general anesthesia in cardiac surgery. A diagnosis of AMAN was considered, but intravenous immunoglobulin showed little efficacy. Magnetic resonance imaging of the patient later revealed BMMI with "snake eyes appearance," and he was found to have severe vertebral artery stenosis. Considering the association between severe coronary heart disease and cerebrovascular stenosis, we highlight the significance of preoperative evaluation and comprehensive management of the cerebrovascular system for certain patients.

Fulminant Guillain-Barré syndrome developed after surgical treatment of intracranial hemorrhage due to arteriovenous malformation: a case report

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder. GBS after surgical treatment of intracranial hemorrhage due to arteriovenous malformation (AVM) is even rarer. We present a 62-year-old man diagnosed with intracranial AVM and cerebral hemorrhage. He developed GBS after the operation for AVM and cerebral hemorrhage. Following surgical excision of AVM and cerebral hematoma, the patient developed generalized weakness, with subsequent quadriplegia and life-threatening dyspnea. The diagnosis was confirmed to be the acute motor-sensory axonal neuropathy subtype of GBS after cerebrospinal fluid analysis and antibody tests. The patient responded poorly to immunoglobulin and steroid therapy. His family abandoned further management and signed out of the hospital against medical advice. Despite being rare, GBS can occur after intracranial hemorrhage and surgery. Clinicians should rule out GBS when patients show no improvement or develop new neurologic.

Guillain-Barré syndrome triggered by surgery in a Chinese population: a multicenter retrospective study

Background

Surgery is a potential trigger of Guillain-Barré syndrome (GBS), a disorder which leads to an autoimmune-mediated attack of peripheral nerves. The present study was designed to explore clinical features of post-surgical GBS compared with those of general GBS in order to provide better clinical advice to patients undergoing surgery.

Methods

The medical records of GBS patients who were seen at 31 tertiary hospitals in southern China between January 1, 2013 and September 30, 2016 were retrospectively analyzed. Post-surgical GBS was defined as symptoms of GBS within 6 weeks after surgery. Clinical features of post-surgical GBS are described and are compared with general GBS.

Results

Among the 1001 GBS patient cases examined in this study, 45 (4.5%) patient cases exhibited symptoms of GBS within 6 weeks of undergoing surgery. Within this group, 36 (80.0%) patients developed initial symptoms of limb weakness. The average interval between surgery and symptom onset was 13.31 days. The most common type of surgery which triggered GBS was orthopedic surgery, followed by neurological surgery. Compared to general GBS, post-surgical GBS was characterized by a higher proportion of severe patients (Hughes functional grading scale (HFGS) score ≥ 3) upon admission and at nadir, higher HFGS scores at discharge, and longer hospital stays. Post-surgical GBS patients also had a significantly higher frequency of the acute motor axonal neuropathy subtype (37.9 vs. 14.2, respectively; P = 0.001).

Conclusion

Surgery is probably a potential trigger factor for GBS, especially orthopedic surgery. Infections secondary to surgery may play a role. The possibility of preceding (post-operative) infections was not excluded in this study. Clinical presentation of post-surgical GBS is characterized by a more severe course and poorer prognosis, and should be closely monitored.

Trial registration

chicTR-RRc-17,014,152.

Guillain-Barre Syndrome Amid Osteosarcoma Treatment: A Therapeutic Dilemma and Literature Review

Guillain-Barre syndrome (GBS) is a clinical syndrome with multiple variants. GBS is defined as an acute demyelinating polyneuropathy commonly preceded by infection (bacterial or viral), trauma, or inflammatory processes, which triggers an autoimmune response that affects the peripheral nervous system. This case report describes a patient with high-grade osteosarcoma that completed neoadjuvant chemotherapy and underwent surgical resection with no immediate complications. Fourteen days after the surgery, the patient developed an acute inflammatory demyelinating polyradiculopathy consistent with GBS. As the five-year survival without chemotherapy is only around 20%, this challenging clinical scenario raised questions regarding adjuvant chemotherapy's safe completion in this setting.

Trauma-Related Guillain-Barré Syndrome: Systematic Review of an Emerging Concept

Guillain-Barré syndrome (GBS) is mainly associated with preceding exposure to an infectious agent, although the precise pathogenic mechanisms and causes remain unknown. Increasing evidence indicates an association between trauma-related factors and GBS. Here, we performed a systematic review, summarized the current scientific literature related to the onset of GBS associated with trauma, and explored the possible pathogenesis. A literature search of various electronic databases was performed up to May 2020 to identify studies reporting diverse trauma-related triggers of GBS. Data were extracted, summarized descriptively, and evaluated with respect to possible mechanisms. In total, 100 publications, including 136 cases and 6 case series involving GBS triggered by injury, surgery, intracranial hemorrhage, and heatstroke, met our eligibility criteria. The median age of the patients was 53 [interquartile range (IQR) 45-63] years, and 72.1% of the patients were male. The median number of days between the trigger to onset of GBS symptoms was 9 (IQR 6.5-13). Overall, 121 patients (89.0%) developed post-injury/surgical GBS, whereas 13 (9.6%) and 2 (1.5%) patients had preexisting spontaneous intracranial hemorrhage and heatstroke, respectively. The main locations of injury or surgeries preceding GBS were the spine and brain. Based on available evidence, we highlight possible mechanisms of GBS induced by these triggers. Moreover, we propose the concept of "trauma-related GBS" as a new research direction, which may help uncover more pathogenic mechanisms than previously considered for typical GBS triggered by infection or vaccination.

Polyneuropathy in Young Siberian Huskies Caused by Degenerative and Inflammatory Diseases

Polyneuropathy is defined as the simultaneous dysfunction of several peripheral nerves. In dogs, a number of breeds are predisposed to a variety of immune-mediated and/or degenerative inherited forms of polyneuropathy, with laryngeal paralysis and/or megaesophagus as important clinical features of many of these conditions. This case series describes degenerative and inflammatory polyneuropathies in 7 young Siberian huskies that were categorized based on clinicopathological characteristics as follows: (1) slowly progressive laryngeal paralysis and megaesophagus caused by primary axonal degeneration with large fiber loss (n = 2); (2) slowly progressive polyneuropathy without megaesophagus or laryngeal paralysis caused by primary axonal degeneration with large fiber loss (n = 2); (3) acute inflammatory demyelinating neuropathy causing sensory, motor and autonomic nerve deficits (n = 2); and (4) ganglioradiculitis (sensory neuronopathy; n = 1). Based on the predominantly young age at onset, slow progression, relatedness of affected dogs, and clinical and pathological similarities with inherited neuropathies reported in other dog breeds, a hereditary basis for the degenerative polyneuropathies in Siberian huskies is suspected. However, 5 different mutations in 3 genes known to cause polyneuropathy in other dog breeds (NDRG1, ARHGEF10, or RAB3GAP1) were not detected in the affected Siberian huskies suggesting that more genetic variants remain to be identified. This study highlights the varied underlying lesions of polyneuropathies in young Siberian huskies.

Guillain-Barré Syndrome After a Gunshot Wound to the Thoracic Spine

BACKGROUND

Guillain-Barré syndrome (GBS) is a rare but well-documented cause of paralysis, often occurring after infection. Few cases have been reported in association with spinal cord injury (SCI), which masks the characteristic ascending paralysis. To our knowledge, this is the first reported case of confirmed GBS during the clinical course of thoracic paraplegia due to a gunshot wound (GSW).

CASE DESCRIPTION

A 23-year-old male presented with a GSW to the right axilla that lodged in the spinal canal at the level of T4, causing right hemothorax and American Spinal Injury Association A paraplegia. He had full strength in bilateral upper extremities until 2 weeks after the injury, at which time he developed progressive weakness in the arms with associated paresthesias and dyspnea. Within 5 days, he was intubated and nearly quadriplegic. Cerebrospinal fluid analysis and electromyography led to a diagnosis of GBS. He was treated with plasmapheresis and experienced rapid and marked recovery in respiratory and upper extremity motor function.

CONCLUSIONS

The differential diagnosis for new-onset weakness in patients with GSW-induced SCI is complicated by the inability to obtain magnetic resonance imaging. This unique case of GBS in a patient with T4 paraplegia highlights the importance of obtaining a thorough history and using diagnostic tools to explore possibilities beyond surgery.

Surgery and Guillain-Barré Syndrome: A Single-Center Retrospective Study Focused on Clinical and Electrophysiological Subtypes

BACKGROUND

Surgery-related Guillain-Barré syndrome (GBS) is often underestimated and sometimes difficult to diagnose. This study aimed to elucidate the clinical features and electrophysiological subtypes of post-surgical GBS.

METHODS

We retrospectively reviewed 17 patients who developed post-surgical GBS after a recent surgery between 2015 and 2019. Clinical characteristics, electrophysiological examinations, lumbar puncture results and prognosis were assessed. As controls, we selected 66 patients hospitalized with non-surgical GBS.

RESULTS

The median duration from the surgery to the onset of GBS symptoms was 16.0 days. The main types of surgeries preceding GBS were orthopedic, gastrointestinal and neurosurgery. Symmetrical distal limbs weakness was present in all 17 post-surgical GBS patients. The incidence of respiratory failure, autonomic dysfunction and muscle atrophy in post-surgical GBS patients was significantly higher than that in non-surgical GBS patients. Hughes Functional Grading Scale (HFGS) scores were also higher in the post-surgical GBS group both at the time of peak disease and 6 months after discharge. Electrophysiological studies revealed significant motor amplitudes reduction with relative preserved nerve conduction velocities and distal latencies, suggesting axonal subtypes of GBS.

CONCLUSION

GBS should be considered in patients with rapidly progressive muscle weakness after surgery. Such patients often exhibit axonal subtypes of GBS with severe motor dysfunction, high risk of respiratory failure, and poor prognosis.

Guillain-Barré Syndrome and Posterior Reversible Encephalopathy Syndrome following Spinal Surgery

Guillain-Barré syndrome (GBS) typically occurs after gastroenteritis and respiratory tract infection, but surgery has also been considered one of the triggers. Posterior reversible encephalopathy syndrome (PRES) is a rare complication of GBS. A normotensive female in her 70s presented ascending paralysis and frontal-parieto-occipital subcortical lesions with intermittent hypertension after spinal surgery. Nerve conduction studies revealed demyelinating polyneuropathy. The patient's brain lesions disappeared with amelioration of hypertension. She was diagnosed with the demyelinating form of GBS and PRES caused by intermittent hypertension. Intravenous immunoglobulin G (IVIG) improved her symptoms without exacerbation of the PRES. Surgery can be a trigger of GBS, and GBS can cause PRES by hypertension and present as central nervous lesions. It is important to treat hypertension before using IVIG when PRES is suspected as a complication of GBS, since the encephalopathy can be exacerbated by IVIG. There may be more undiagnosed cases of the coexistence of GBS and PRES after surgery because surgery itself can also cause PRES. Proper control of blood pressure and confirmation of negative central nervous lesions are required to treat GBS patients with IVIG safely.

Guillain-Barré syndrome and influenza vaccines: current evidence

OBJECTIVE

Guillain-Barré Syndrome (GBS) as a consequence of influenza vaccination is a relevant topic, yet to be clarified, which raises concern both amongst health care personnel and the general population. Every study and pharmacovigilance system point to need of further research and the importance of continuous monitoring of safety regarding influenza vaccines. The aim of the present study is to investigate the publication of new data since the realisation of our meta-analysis of GBS and influenza vaccines (published in 2015).

METHODS

A systematic revision of PubMed, Embase, and Web of Knowledge (WOS) databases has been carried out. These report observational studies assessing GBS risk after the administration of influenza vaccines from May 2014 up to July 20th, 2017.

RESULTS

The research yielded 107 articles. Only three studies met established inclusion criteria and referred to an estimation GBS risk after some influenza vaccine. Two studies investigated GBS risk by the pandemic A/H1N1 vaccine, while only one looked into season vaccines.

CONCLUSIONS

The present systematic review, conducted after the publication of our previous meta-analysis, seems to confirm its previous results. Therefore, GBS should be considered an infrequent adverse effect of influenza vaccination, which should not negatively influence its acceptance. Unfortunately, very few of the systematically surveyed studies meeting inclusion criteria. This fact sharply contrasts with the current consensus as to the need of continuously monitoring the safety of influenza vaccines.

Porfiria intermitente aguda como desencadenante de síndrome de Guillain-Barre

Introducción. La porfiria es un conjunto de enfermedades metabólicas que tienen como base fisiopatológica la acumulación de precursores tóxicos. Su similitud clínica con enfermedades como el síndrome de Guillain-Barre puede retrasar el diagnostico, aumentando la posibilidad de complicaciones.Presentación del caso. Paciente femenino quien presentó síntomas inespecíficos de porfiria y síndrome de Guillain-Barre. La mujer fue evaluada de manera integral y recibió tratamiento para ambas patologías, respondiendo de manera inusual.Conclusión. La respuesta farmacológica atípica encontrada y la relación causa-efecto entre ambas entidades se justifica a la luz de sus procesos fisiopatológicos y la respuesta inmune desencadenada por los mismos.

Clinical Characteristics of Intravenous Injection of Monosialotetrahexosyl Ganglioside Sodium-Related Guillain-Barre Syndrome

Introduction: Guillain Barre Syndrome (GBS) is an acute inflammatory immune-mediated multiple nerve root neuropathy. GBS primarily damages the spinal nerve root and peripheral nerves, but can also affect the cranial nerves and cause acute demyelination. This study analyzed the clinical features of intravenous injection of monosialotetrahexosyl ganglioside sodium-related Guillain-Barre syndrome (GRD-GBS). Methods: We retrospectively studied 12 patients who developed GRD-GBS after receiving monosialotetrahexosyl ganglioside sodium treatment in association with recent trauma, surgery, acute cerebrovascular disease, or chronic peripheral neuropathy. Clinical characteristics, electrophysiological examinations, serum-specific antibodies, and prognosis were assessed. As controls, we selected 12 patients hospitalized with non-ganglioside-related (NGRD)-GBS. Results: The positive rate of the ganglioside antibody test was significantly higher in the GRD-GBS group (66.67%) than in the NGRD-GBS group (8.33%). CSF protein levels were similar between the groups, but the incidence of blood-nerve-barrier (BNB) disruption was higher in the GRD-GBS group. Patient scores for the Hughes Functional Grading Scale (HFGS), a disability scale, were higher (more severe disability) in the GRD-GBS group than in the NGRD-GBS group. The HFGS scores of the GRD-GBS group did not change between peak onset and 30 days after discharge, but did change significantly by 90 days after discharge, while scores were significantly lower at both 30 and 90 days after discharge in the NGRD-GBS group. Conclusions: GRD-GBS patients showed more severe clinical manifestations, poorer prognosis, and slower recovery than patients with NGRD-GBS. Ganglioside treatment should be used with extreme caution in patients with trauma that damages the BNB.

Guillain-Barré syndrome as a complication of hypertensive basal ganglia haemorrhage

We aimed to study the potential relationship of Guillain-Barré syndrome (GBS) and intracranial haemorrhage (ICH). We present a case of a 70-year-old hypertensive woman who developed global weakness, eventually becoming quadriplegic, during an inpatient stay for treatment of a basal ganglia haemorrhagic stroke. Guillain-Barré syndrome was confirmed and treatment initiated. She responded well to intravenous immunoglobulin treatment and then subsequently continued with rehabilitation. There have been a few case reports of GBS as a complication of spontaneous intracranial haemorrhage (ICH) or traumatic brain injury. It may not be a coincidence that our patient developed GBS shortly after presentation. There may be an immunological explanation with immune activation following neuronal injury after ICH with associated blood-brain barrier breakdown. GBS following ICH adds further complexity to treating patients who are already critically ill. If patients develop new weakness after ICH, there should be a high index of suspicion for GBS. It should be distinguished from critical illness neuropathy/myopathy and other causes of weakness in critical care patients because the treatment is very different. Immune activation and sensitization to myelin-associated proteins may be the underlying pathophysiological basis.

A case of surgically-associated anti GQ1b antibody syndrome accompanied by saccadic ping pong gaze

Background

Periodic alternating ping-pong gaze (PPG) is a rare disease with few reports. To our knowledge, there was no report on anti GQ1b antibody syndrome accompanied by PPG. This paper reported a case of anti GQ1b antibody syndrome with Bickerstaff’s Encephalitis (BBE) overlapping classic Guillain-Barre Syndrome (GBS) after aortic valve replacement, accompanied by an excessive PPG in the course of diagnosis and treatment, this was indeed rarely.

Case presentation

A 55-year-old male patient was admitted to our hospital with intermittent chest tightness for 3 months, and his condition has worsened in the past 10 days. Aortic valve replacement was performed because of the existence of the moderate and severe stenosis of aortic valve. Horizontal movement of the eyeball was involuntarily slow. The eyeball hovered and returned from one side to the other horizontally for 3–4 s per cycle. In combination with the patient’s typical clinical and laboratory tests, the final diagnosis was anti GQ1b antibody syndrome BBE combined with GBS, accompanied by saccadic ping pong gaze. Intravenous immunoglobulin (0.4 g/kg) was given for immunomodulation, methylprednisolone (1000 mg) therapy and symptomatic treatment were performed in the patient.

Conclusions

The patients were discharged from hospital on the thirtieth day because of economic reasons. After 6 months of follow up, the patients left behind a lack of fluency in speech and limb mobility, but the basic life can be taken care of by himself.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1258-x) contains supplementary material, which is available to authorized users.

Incidence and outcome of Guillain-Barré syndrome in Iceland: A population-based study

OBJECTIVE

In this study, we determine the incidence and outcomes of Guillain-Barré syndrome (GBS) in Iceland over a 20-year period.

METHOD

Cases were identified from the records of both referral hospitals in the country. All cases met the Brighton Criteria for GBS. Disability was assessed at diagnosis, peak of symptoms, discharge, and follow-up using the Guillain-Barré Disability Scale.

RESULTS

Sixty-three individuals fulfilled the diagnostic criteria with an average age of onset of 46 years (range 1-89 years) and a male:female ratio of 1. The average annual incidence was 1.1 per 100 000 person-years. Nerve conduction studies were consistent with demyelinating polyneuropathy in 87% of cases, acute motor axonal neuropathy (AMAN) in 4%, and were normal in 9%. Treatment was received by 89% of patients and included IVIG (84%), plasmapheresis (8%), or both treatments (3%). Mechanical ventilation was required by 22% of patients. Long-term follow-up with an average length of 6.5 years was available for 98% of patients, and the average GBS disability score at follow-up was 0.9. Four deaths related to GBS (6%) were observed.

CONCLUSION

We believe we have identified all patients diagnosed with GBS in Iceland during the study period, with an incidence comparable to recent studies from well-defined populations around the world. Our reported mortality is similar to or higher than other population-based studies. At follow-up, 13% of patients still required a walking aid, but most survivors (74%) had minor or no symptoms.

Surgery and risk of Guillain-Barré syndrome: A French nationwide epidemiologic study

OBJECTIVE

To assess the association between Guillain-Barré syndrome (GBS) and recent surgery based on French nationwide data.

METHODS

Data were extracted from the French health administrative databases (SNIIRAM/PMSI). All patients hospitalized for GBS between 2009 and 2014 were identified by ICD-10 code G61.0 as main diagnosis. Patients previously hospitalized for GBS in 2006, 2007, and 2008 were excluded. Surgical procedures were identified from the hospital database. Hospitalizations for surgery with no infection diagnosis code entered during the hospital stay were also identified. The association between GBS and a recent surgical procedure was estimated using a case-crossover design. Case and referent windows were defined as 1-60 days and 366-425 days before GBS hospitalization, respectively. Analyses were adjusted for previous episodes of gastroenteritis and respiratory tract infection, identified by drug dispensing data.

RESULTS

Of the 8,364 GBS cases included, 175 and 257 patients had undergone a surgical procedure in the referent and case windows, respectively (adjusted odds ratio [OR] = 1.53, 95% confidence interval [CI]: 1.25-1.88). A slightly weaker association was observed for surgical procedures with no identified infection during the hospitalization (OR = 1.40, 95% CI: 1.12-1.73). Regarding the type of surgery, only surgical procedures on bones and digestive organs were significantly associated with GBS (OR and 95% CI = 2.78 [1.68-4.60] and 2.36 [1.32-4.21], respectively).

CONCLUSION

In this large nationwide epidemiologic study, GBS was moderately associated with any type of recent surgery and was more strongly associated with bone and digestive organ surgery.

Posterior Reversible Encephalopathy Syndrome and Guillain-Barré Syndrome after Head Injury: Case Report

We report a case of head injury with posterior reversible encephalopathy syndrome (PRES), followed by Guillain-Barré syndrome (GBS). A 74-year-old man was brought to our hospital after a fall. Computed tomography revealed intracranial hemorrhage. Magnetic resonance imaging showed bilateral reversible intensities with features of vasogenic edema in parietooccipital areas, suggesting PRES. After admission, weakness and areflexia of extremities and respiratory muscles developed gradually, which favored a diagnosis of GBS. Common etiologies of PRES were absent. Concurrent occurrence of PRES and GBS is rare. Given that PRES can be an initial manifestation of GBS, GBS must be considered in head trauma patients with PRES.

Effector/memory CD8+ T cells synergize with co-stimulation competent macrophages to trigger autoimmune peripheral neuropathy

Autoimmune peripheral neuropathy (APN) such as Guillain Barre Syndrome (GBS) is a debilitating illness and sometimes life threatening. The molecular and cellular mechanisms remain elusive but exposure to environmental factors including viral/bacterial infection and injury is highly associated with disease incidence. We demonstrated previously that both male and female B7.2 (CD86) transgenic L31 and L31/CD4KO mice develop spontaneous APN. Here we further reveal that CD8⁺ T cells in these mice exhibit an effector/memory phenotype, which bears a resemblance to the CD8⁺ T cell response following persistent cytomegalovirus (CMV) infection in humans and mice, whilst CMV has been considered as one of the most relevant pathogens in APN development. These activated, peripheral myelin Ag specific CD8⁺ T cells are required for the disease initiation. While an injury to a peripheral nerve results in Wallerian degeneration in control littermates, the same injury accelerates the development of APN in other non-injured nerves of L31 mice which have a predisposed inflammatory background consisting of effector/memory CD8⁺ T (CD8⁺ T_EM) cells. However, CD8⁺ T_EM cells alone are not sufficient. A certain threshold of B7.2 expression on nerve macrophages is an additional requisite. Our findings reveal that indeed, the synergism between CD8⁺ T_EM cells and co-stimulation competent macrophages is crucial in inducing autoimmune-mediated peripheral neuropathy. The identification of decisive molecular/cellular players connecting environmental triggers and the occurrence of APN provides opportunities to prevent disease onset, reduce relapses and develop new therapeutic strategies.

Early predictors of Guillain-Barré syndrome in the life course of women

Background

We sought to determine if immune disorders early in life were associated with the later risk of Guillain-Barré syndrome, a neurological disorder thought to be infection-related.

Methods

We conducted a longitudinal cohort study with 16 108 819 person-years of follow-up for a population of 1 108 541 parous women in Quebec, Canada (1989-2014). The outcome was Guillain-Barré syndrome. We identified women with potential risk factors for future Guillain-Barré syndrome, including immune-mediated and rheumatological diseases, cancer, transfusion, surgical procedures and pregnancy-specific disorders. We estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association of risk factors with later onset of Guillain-Barré syndrome, adjusted for personal characteristics of women.

Results

The overall incidence of Guillain-Barré syndrome was 1.42 per 100 000 person-years. Incidence was higher for women with immune-mediated (8.79 per 100 000 person-years) and rheumatological disorders (9.84 per 100 000 person-years), transfusion (4.41 per 100 000 person-years), and preeclampsia (2.62 per 100 000 person-years). Immune-mediated disorders were associated with six times the risk of Guillain-Barré syndrome (HR 6.57, 95% CI 3.58 to 12.04), rheumatological disorders with seven times the risk (HR 7.23, 95% CI 3.21 to 16.28), transfusion three times the risk (HR 3.58, 95% CI 1.83 to 6.98) and preeclampsia two times the risk (HR 2.01, 95% CI 1.29 to 3.12). Women with other potential risk factors did not have an increased risk of Guillain-Barré syndrome.

Conclusions

Immune-related conditions that occur early in life are associated with an increased risk of Guillain-Barré syndrome. The pathophysiology of Guillain-Barré syndrome may extend beyond infectious triggers.

Clinical and electrophysiological features of post-traumatic Guillain-Barré syndrome

BACKGROUND

Post-traumatic Guillain-Barré syndrome (GBS) is a rarely described potentially life-threatening cause of weakness. We sought to elucidate the clinical features and electrophysiological patterns of post-traumatic GBS as an aid to diagnosis.

METHODS

We retrospectively studied six patients diagnosed with post-traumatic GBS between 2014 and 2016 at Tianjin Medical University General Hospital, China. Clinical features, serum analysis, lumbar puncture results, electrophysiological examinations, and prognosis were assessed.

RESULTS

All six patients had different degrees of muscular atrophy at nadir and in two, respiratory muscles were involved. Five also had damaged cranial nerves and four of these had serum antibodies against gangliosides. The most common electrophysiological findings were relatively normal distal latency, prominent reduction of compound muscle action potential amplitude, and absence of F-waves, which are consistent with an axonal form of GBS.

CONCLUSIONS

It is often overlooked that GBS can be triggered by non-infectious factors such as trauma and its short-term prognosis is poor. Therefore, it is important to analyze the clinical and electrophysiological features of GBS after trauma. Here we have shown that electrophysiological evaluations are helpful for diagnosing post-traumatic GBS. Early diagnosis may support appropriate treatment to help prevent morbidity and improve prognosis.

The Current State of Macrolide Resistance in Campylobacter spp.: Trends and Impacts of Resistance Mechanisms

Campylobacter spp., especially Campylobacter jejuni and C. coli, are leading bacterial foodborne pathogens worldwide. In the United States, an estimated 0.8 million cases of campylobacteriosis occur annually, mostly involving C. jejuni Campylobacteriosis is generally self-limiting, but in severe cases, treatment with antibiotics may be mandated. The increasing incidence of fluoroquinolone resistance in Campylobacter has rendered macrolides such as erythromycin and azithromycin the drugs of choice for human campylobacteriosis. The prevalence of macrolide resistance in C. jejuni remains low, but macrolide resistance can be common in C. coli Substitutions in the 23S rRNA gene, specifically A2075G, and less frequently A2074C/G, remain the most common mechanism for high-level resistance to macrolides. In C. jejuni, resistance mediated by such substitutions is accompanied by a reduced ability to colonize chickens and other fitness costs, potentially contributing to the low incidence of macrolide resistance. Interestingly, similar fitness impacts have not been noted in C. coli Also noteworthy is a novel mechanism first reported in 2014 for a C. coli isolate from China and mediated by erm(B) harbored on multidrug resistance genomic islands. The incidence of erm(B) appears to reflect clonal expansion of certain strains, and whole-genome sequencing has been critical to the elucidation of erm(B)-associated macrolide resistance in Campylobacter spp. With the exception of one report from Spain, erm(B)-mediated macrolide resistance has been restricted to Campylobacter spp., mostly C. coli, of animal and human origin from China. If erm(B)-mediated macrolide resistance does not confer fitness costs in C. jejuni, the range of this gene may expand in C. jejuni, threatening to compromise treatment effectiveness for severe campylobacteriosis cases.