Guillain-Barré syndrome

Anesthesia Experience for Guillain-Barre Syndrome in Endoscopy Procedures: A Retrospective Case Series

Objective

To determine whether patients with previous Guillain-Barre syndrome (GBS) encountered anesthetic complications that necessitated an unanticipated escalation of care during endoscopic procedures.

Patients and Methods

We reviewed 309 patients diagnosed with GBS who underwent 537 gastrointestinal endoscopic procedures at all Mayo Clinic geographic sites from January 1, 2012 to May 25, 2023. Our study included patients with GBS from acute onset, chronic/relapsing to full/partial recovery phases. We assessed whether GBS correlated with unanticipated escalations of care, defined as intraprocedural escalation between types of sedation or unanticipated hospital admission after an endoscopic procedure.

Results

No case exhibited anesthesia-related complications or required escalations of care. A total of 85% of cases (458) were performed without a secured airway. Within 6 months of GBS acute onset, 61% of cases (16 of 26) required general endotracheal anesthesia. Nine of 26 acute onset cases involved patients already intubated or with tracheostomies, primarily to place percutaneous endoscopic gastrostomy feeding tubes to advance care outside of the intensive care unit. 33 cases received paralyzing doses of succinylcholine; 3 involved patients with reported residual muscle weakness.

Conclusion

Acute onset GBS cases frequently present with bulbar dysfunction, respiratory distress, and muscle weakness. Patients within 6 months of acute onset should delay elective endoscopic procedures, whereas urgent/emergent ones should be scheduled on a case-by-case basis. Beyond 6 months, most patients exhibit dramatic functional recovery, allowing for administration of sedation without a protected airway. Regardless of time since onset, residual GBS symptoms-particularly respiratory distress and bulbar dysfunction-can help risk stratify patients for periprocedural aspiration risks.

Patient-Reported Outcome Measures for Assessing Health-Related Quality of Life in Patients With Polyneuropathies, Focusing on Guillain-Barré Syndrome and Chronic Inflammatory Demyelinating Polyneuropathy: A Systematic Review of Measurement Properties

Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) are immune-mediated peripheral neuropathies. Despite treatment, patients may report residual deficits, pain, and fatigue with considerable impact on quality of life. A systematic review was conducted of the methodological quality of current patient-reported outcome measures (PROMs) for measuring health-related quality of life (HRQoL) in patients with GBS and CIDP. A literature search was conducted in EMBASE, MEDLINE, Web of Science, and Google Scholar. PROMs developed to measure (aspects of) HRQoL in patients with polyneuropathy were classified using the Wilson and Cleary model. Measurement properties were evaluated in accordance with Consensus-based Standards for selection of health Measurement Instruments (COSMIN) guideline. A total of 57 articles identified 31 unique PROMs that are used for measuring HRQoL in patients with polyneuropathies. Of these, 22 measured symptom status, 19 functional status, and 4 general health perception. Eight PROMs were developed or validated in patients with GBS/CIDP. None of the PROMs demonstrated sufficient content validity for recommendation in this population. Only the Rasch-built Fatigue Severity Scale (R-FSS) performed sufficiently across all other measurement properties. The Inflammatory Rasch-built Overall Disability Scale (I-RODS) and IN-QoL are not recommended for use because of insufficient construct validity. GBS Patient Experience Questionnaire, Chronic Acquired Polyneuropathy Patient-Reported Index (CAP-PRI), Fatigue Severity Scale (FSS), R-FSS, Rotterdam Handicap Scale (RHS) and the 36-Item Short Form Health Survey (SF-36) need further validation. PROMs of good quality assessing all relevant aspects of HRQoL are required for better insight in HRQoL in patients with GBS and CIDP.

Comprehensive analysis of acute flaccid paralysis with and without myelitis in Taiwanese children

BACKGROUND

Acute flaccid paralysis (AFP) is a clinical syndrome marked by the sudden onset of muscle weakness or paralysis, requiring immediate medical intervention due to its potential for significant morbidity and mortality. Despite extensive studies on AFP, comparative analyses between cases with myelitis (M-AFP) and non-myelitis (NM-AFP) remain scarce. This study seeks to address this gap by analyzing demographic, clinical, and etiological distinctions between these groups.

METHODS

A retrospective study was conducted on 39 pediatric AFP patients diagnosed between 2012 and 2021. Participants were categorized into M-AFP (n = 22) and NM-AFP (n = 17) groups based on clinical symptoms and diagnostic imaging. Demographic and clinical characteristics, laboratory findings, and underlying causes were analyzed to identify differences between the groups. Statistical methods were employed to assess significance.

RESULTS

Significant clinical differences were observed: limb numbness was more prevalent in M-AFP, while myalgia was more common in NM-AFP. Elevated cerebrospinal fluid white blood cell (CSF WBC) counts were noted in M-AFP cases, though the difference was not statistically significant. Etiologies of M-AFP included multiple sclerosis and enterovirus infections, while NM-AFP involved polymyositis, Guillain-Barré syndrome, and hypokalemic periodic paralysis.

CONCLUSIONS

This study highlights the distinct clinical and etiological profiles of M-AFP and NM-AFP, emphasizing the need for tailored diagnostic strategies to enhance outcomes in pediatric patients.

Elevated Serum Amyloid A2 and A4 in Patients With Guillain-Barré Syndrome

BACKGROUND AND PURPOSE

Guillain-Barré syndrome (GBS) is an autoimmune-mediated disorder characterized by demyelinating or axonal injury of the peripheral nerve. Our aim is to determine whether serum amyloid A (SAA) is a biomarker of demyelinating injury and disease severity in patients with GBS.

METHODS

This study retrospectively enrolled 40 patients with either the demyelinating or axonal GBS and sex- and age-matched controls with other neurological diseases as well as healthy subjects. The demographic and clinical features at entry were collected. The serum levels of the SAA isoforms SAA1, SAA2, and SAA4 were determined in the patients with GBS and the controls using the enzyme-linked immunosorbent assay and analyzed for the associations between levels of different SAA isoforms and the clinical features of the patients.

RESULTS

The levels of SAA2 and SAA4 were significantly higher in patients with GBS than in both the other neurological disease controls and the healthy subjects (p<0.05 for all). The level of SAA1 did not differ between patients with GBS and the controls. The level of SAA2 was considerably higher in GBS patients with antecedent infection than in those without infection (p=0.020). The levels of different SAA isoforms were not associated with the disease severity or other clinical features of patients with GBS (p>0.05 for all).

CONCLUSIONS

Increased levels of SAA2 and SAA4 may only represent the acute inflammatory status and so cannot be utilized as biomarkers of the disease severity or demyelinating injury in patients with GBS.

Relationship between sympathetic skin response and RR interval variation with the prognosis of Guillain-Barre syndrome patients

BACKGROUND

Guillain-Barré syndrome (GBS) is an inflammatory disorder causing severe disability and death. The sympathetic skin response (SSR) and RR interval variability are non-invasive tests that measure autonomic dysfunction. The aim of this study was to investigate the relationship of SSR and RR interval variation with prognosis in patients with GBS in Isfahan, Iran.

METHODS

This cross-sectional study analyzed 32 patients with GBS in Iran between 2023 and 2024. Patients underwent EMG-NCV during their hospitalization, measuring SSR and RR interval variation. Patients' GBS disability scores were calculated and recorded on the day of hospital discharge and one month after. Gender distribution, types of GBS, intubation status, length of ICU and ward stay, GBS disability scores, and plasmapheresis volume are also compared.

RESULTS

In 19 patients (59.3%), both SSR and RR interval variability were abnormal. There were no statistically significant differences between patients with and without autonomic dysfunction (AD) for the variables compared. There were no significant differences between groups with normal and abnormal SSR and between groups with normal and abnormal RR interval variation. Age and intubation status significantly affect GBS disability scores at discharge and one month after discharge, while gender does not significantly impact any outcomes. Many variables, such as age, gender, type of GBS, intubation status, and lengths of stay, do not show significant differences between the compared groups based on AD, SSR, and RR interval variability.

CONCLUSIONS

The study highlights the lack of correlation between AD, SSR, and RR interval variation in patients with GBS.

Miller-Fisher syndrome subtype with isolated bilateral mydriasis: a pediatric case report

BACKGROUND

Miller-Fisher Syndrome (MFS), a distinct subtype of Guillain-Barré Syndrome (GBS), accounts for 5% of GBS cases and classically manifests with the triad of ophthalmoplegia, ataxia, and areflexia. Isolated bilateral mydriasis as the sole presenting feature is exceptionally rare, particularly in pediatric populations. While pupillary abnormalities have been documented in adult MFS cases, their diagnostic significance and management in children remain poorly characterized. We report a novel pediatric case of a 7-year-old girl presenting with 7 days of unexplained bilateral painless mydriasis unresponsive to light accommodation. Initial symptomatic management targeting potential toxic or neuropathic etiologies proved ineffective. Recognition of this atypical presentation prompted serological evaluation for autoimmune neuropathy markers, which demonstrated positivity for GQ1b IgM, GQ1b IgG, and GT1a IgG antibodies, confirming MFS diagnosis. Rapid clinical improvement followed intravenous immunoglobulin (IVIG) therapy. This case highlights the diagnostic challenges posed by incomplete or atypical MFS manifestations and underscores the necessity of early antibody testing in unexplained autonomic or neurological symptoms.

CONCLUSION

This report expands the phenotypic spectrum of pediatric MFS by demonstrating isolated bilateral mydriasis as a potential initial manifestation, clinicians evaluating pupillary dilation should consider MFS in differential diagnoses. Future studies should continue to explore the pathophysiological link between anti-GQ1b antibodies and isolated autonomic dysfunction in pediatric MFS.

Blood nerve barrier permeability enables nerve targeting of circulating nanoparticles in experimental autoimmune neuritis

Guillain-Barré syndrome (GBS) is a devastating autoimmune disease of the peripheral nervous system (PNS) with limited treatment options. Several studies have shown attenuation of the well-characterized GBS preclinical experimental autoimmune neuritis (EAN) model with systemically administered therapeutic compounds via anti-inflammatory or immunomodulatory mechanisms. Despite this, clinical advancement of these findings is limited by dosing that is not translatable to humans or is associated with off-target and toxic effects. This is due, in part, to the blood-nerve barrier (BNB), which restricts access of the circulation to peripheral nerves. However, during acute neuroinflammation, the normally restrictive BNB exhibits increased vascular permeability and enables immune cell infiltration. This may offer a unique window to access the otherwise restricted peripheral nerve microenvironment for therapeutic delivery. Here, we assessed the degree to which BNB permeability and immune cell infiltration over the course of EAN enables accumulation of circulating nanoparticles. We found that at disease stages defined by distinct clinical scores and pathology (onset, effector phase, and peak of EAN severity), intravenously administered small molecules and nanoparticles ranging from 50 to 150 nm can permeate into the endoneurium from the endoneurial vasculature in a size- and stage-dependent manner. This permeation occurs uniformly in both sciatic nerves and in proximal and distal regions of the nerves. We propose that this nerve targeting enabled by pathology serves as a platform by which potential therapies for GBS can be reevaluated and investigated preclinically in nanoparticle delivery systems.

The intersection of influenza infection and autoimmunity

The relationship between viral infection and autoimmune manifestations has been emerging as a significant focus of study, underscoring the intricate interplay between viral infections and the immune system. Influenza infection can result in a spectrum of clinical outcomes, ranging from mild illness to severe disease, including mortality. Annual influenza vaccination remains the most effective strategy for preventing infection and its associated complications. The complications arising from acute influenza infection are attributable not only to the direct effects of the viral infection but also to the dysregulated immune response it elicits. Notably, associations between influenza and various autoimmune diseases, such as Guillain-Barré Syndrome (GBS), Type 1 Diabetes (T1D), and antiphospholipid syndrome, have been reported. While viral infections have long been recognized as potential triggers of autoimmunity, the underlying mechanisms remain to be elucidated. Here, we described the pathophysiology caused by influenza infection and the influenza-associated autoimmune manifestations. Current advances on the understanding of the underlying immune mechanisms that lead to the potential strategies were also summarized.

Microscopical anatomy of the peripheral nervous system: An essential notion for understanding the pathophysiology of very early classic Guillain-Barré syndrome

The aim of this paper is to analyze the pathophysiological mechanisms acting in very early classic Guillain-Barré syndrome (GBS) (≤4 days of symptomatic onset). In this inaugural period, both in GBS and its animal model, experimental autoimmune neuritis, the outstanding pathological feature is inflammatory edema predominating in proximal nerve trunks, particularly spinal nerves, and possibly in preterminal nerve segments. Nerve trunks external to the subarachnoid angle possess epi- perineurium that is relatively inelastic and of low compliance. Here such edema can increase endoneurial fluid pressure that, when sufficiently critical, may stretch the perineurium and constrict transperineurial microcirculation, compromising blood flow and producing the potential for ischemic nerve injury, whose consequence is rapid partial or complete loss of nerve excitability. These histopathological features correlate well with electrophysiological and imaging findings reported in early GBS stages. Spinal nerve edema and ischemia help to understand the pattern of Wallerian-like degeneration observed in the axonal form of GBS, predominating in motor spinal roots at their exit from the dura matter (spinal nerves) with centrifugal distribution in more distant motor nerve trunks, and centripetal extension to the distal portion of intrathecal roots. The similarity of initial pathogenic mechanisms between demyelinating and axonal forms of GBS explains why an early increase of serum biomarkers of axonal damage is detected in both forms. In conclusion, knowledge of the microscopic anatomy of the peripheral nervous system is an essential step for a reliable understanding of pathophysiological mechanisms operating in the early phase of any classic GBS subtype.

Guillain-Barré syndrome in patients with Charcot-Marie-Tooth type 1A disease, probably a non-random association

OBJECTIVE

To describe four cases of Charcot-Marie-Tooth disease type 1A (CMT1A) who developed Guillain-Barré syndrome (GBS), respectively the most frequent genetic and inflammatory neuropathies.

METHODS

We described the patients' clinical and electrodiagnostic characteristics.

RESULTS

Our CMT1A patients developed typical GBS at various ages (3 to 76 years). GBS-related clinical manifestations were different within patients, with various severity degrees of seve (weakness, respiratory failure). Nerve conduction studies revealed more severe demyelinating features than expected in patients with no CMT1A. High cerebrospinal fluid protein level was found in 3 patients. GBS outcome was mainly good, although some patients only slowly improved.

CONCLUSIONS

Our cases are close to the previously described cases of acute worsening in CMT1A, and presented with many electrophysiological features of GBS. Overall, GBS prognosis does not seem worse in CMT1A patients than in other patients. If GBS and CMT1A were independent, the expected frequency of co-occurrence of GBS and CMT1A in our two French regions should be 1 case every 137 years. As we observed 4 cases in only 5 years, we suspect that CMT1A is a risk factor of GBS.

SIGNIFICANCE

These cases bring further evidence for a non-random link between inflammatory and genetic neuropathies.

If it does not help, it might hurt: Pharmacodynamics of a second IVIg course in Guillain-Barré syndrome

OBJECTIVES

Intravenous immunoglobulin (IVIg) is an effective treatment for Guillain-Barré syndrome (GBS), but recovery varies between patients. This study aims to evaluate the pharmacokinetics (PK) and pharmacodynamics (PD) of a single and a second IVIg dose (SID) in patients with GBS.

METHODS

Data were analyzed from the SID-GBS trial, a double-blind, randomized, placebo-controlled study. Patients with poor prognosis (modified Erasmus GBS Outcome Score, mEGOS ≥6) after a standard course of IVIg (0.4 g/kg for 5 days) were randomized to receive either SID or placebo. Serum IgG levels were measured at standard serial time points and clinical outcomes were assessed using the GBS disability score and Medical Research Council sum score. PK modeling was performed to predict IVIg exposure and its association with clinical outcomes.

RESULTS

Serum IgG concentration after a single and double course of IVIg was variable, but accurately described by the current PK model. Lower ΔIgG and IVIg exposure were associated with poorer clinical outcomes. SID increased the IgG concentration, but did not result in an improvement in clinical outcome. Serious adverse events, including thromboembolic events, occurred more frequently in the SID group and were associated with lower IVIg exposure.

INTERPRETATION

SID increases serum IgG levels in GBS patients as predicted by the current PK model, but does not improve clinical outcomes and increases the risk of serious adverse events. Model-informed precision dosing may guide individualization of treatment.

Knowledge mapping of Guillain-Barré syndrome from January 2013 to October 2023: A bibliometric analysis

BACKGROUND

With the COVID-19 pandemic and the serious sequelae, foreign factor-induced Guillain-Barré syndrome (GBS) has become a research focus in autoimmune peripheral neuropathies. The study employs a bibliometric system to illustrate the research hotspots and trends in GBS based on pertinent literature from January 2013 to October 2023.

METHODS

The Web of Science Core Collection retrieved articles on GBS from January 1, 2013, to October 28, 2023. These articles were then visualized and statistically evaluated using VOSviewer, CiteSpace software, R version 4.2.1, and Microsoft Office Excel 2019.

RESULTS

A total of 4269 articles on GBS were gathered. The United States of America produced the most publications (28.55%, 1219/4269), followed by China (14.22%, 607/4269). The world's leading country was the United States of America, with the most publications, the most substantial international cooperation, and the highest centrality (0.17). Union of French Research Universities (UDICE)-French Research Universities in France was the most productive organization (189 articles). Lancet was the highest cocited journal (2428), and Professor Jacobs, Bart C., was the most prolific author (93). The most significant increases were shown for the keywords coronavirus, respiratory failure, and coronavirus disease 2019. The novel coronavirus is an emerging virus that may cause GBS, indicating a promising area of research.

CONCLUSIONS

The study on GBS was illustrated using bibliometrics, and it covers trends in international collaboration, publications, and research hotspots. These findings allow the scientific community to pinpoint the novel ideas and directions that will drive future GBS research.

The Utility of Muscle Ultrasound as a Predictor of Outcome in Guillain-Barré Syndrome Patients in the Intensive Care Unit: A Prospective Cohort Study

Aims and background

Guillain-Barré syndrome (GBS) is associated with significant muscle loss, which can result in prolonged intensive care. The aim of this study was to evaluate muscle atrophy in GBS patients using serial ultrasound measurements of rectus femoris cross-sectional area (RFCSA).

Materials and methods

A prospective study was carried out among GBS patients admitted to the intensive care unit (ICU). All clinical and demographic variables were recorded at admission.Ultrasound measurement of RFCSA was done at baseline and 3, 7, and 14 days after ICU admission. Clinical outcomes such as the ICU stay and duration of mechanical ventilation were studied at discharge.

Results

A total of 25 patients were studied. The mean age was 48.96 ± 14.82 years, 44% were female, and 25% experienced significant muscle atrophy in the first 72 hours. The percentage changes in the RFCSA were 5.21 (3.38-8.39), 9.18 (5.52-11.76), and 12.63 (8.65-15.09) on days 3, 7, and 14, respectively. A greater muscle atrophy rate was strongly positively correlated with longer ventilation periods [atrophy day 14 (r = 0.88, p < 0.001)] and atrophy day 7 (r = 0.87, p < 0.001) and total number of ICU days [atrophy day 14 (r = 0.93, p < 0.001)].

Conclusion

Muscle ultrasound (MUSG) shows potential as a tool for monitoring muscle atrophy in GBS patients. However, its ability to reliably identify patients at risk for prolonged ICU stays and mechanical ventilation requires cautious interpretation and further validation due to the absence of a comparator.

Clinical significance

The findings of this study highlight the utility of bedside MUSG as a non-invasive tool for monitoring muscle atrophy in neuromuscular diseases and critically ill patients.Early identification of significant muscle loss allows for timely interventions, risk stratification, and resource optimization, ultimately improving ICU outcomes and patient recovery trajectories.

How to cite this article

Naik SS, Desai M, Krishnakumar M, Nashi S, Varadarajan B. The Utility of Muscle Ultrasound as a Predictor of Outcome in Guillain-Barré Syndrome Patients in the Intensive Care Unit: A Prospective Cohort Study. Indian J Crit Care Med 2025;29(3):262-267.

Initial Management of Neuromuscular Emergencies

Neuromuscular emergencies can be anxiety provoking for neurologist and nonneurologist alike. This review will discuss common causes of neuromuscular respiratory failure and how to treat them. An algorithmic approach to neuromuscular neurology will be employed to help the nonneurologist be more comfortable with acute neuromuscular emergencies.

Is there a link between Hepatitis A virus and Guillain-Barré syndrome? A systematic review of case reports

Introduction

Guillain-Barré syndrome (GBS) is an inflammatory disorder of the peripheral nervous system, causing acute flaccid paralysis. There have been occasional reports linking Hepatitis A virus (HAV) to GBS. Here we aimed to evaluate the current literature on the association between GBS and HAV, exploring potential mechanisms and clinical implications.

Methods

We conducted a systematic search using PRISMA guidelines in PubMed, Web of Science, Embase, and Scopus. Only published case reports or conference abstracts presenting cases of confirmed HAV infection and GBS were included. Data extraction was performed independently by two reviewers, and quality assessment was conducted using the Joanna Briggs Institute critical appraisal tool.

Results

Out of 581 studies identified, 46 studies encompassing 47 cases met the inclusion criteria. The mean age of patients was 29.47 years, with a male predominance (70.2 %). Geographically, most cases were reported in Asia (74.5 %). Clinical manifestations of HAV included fever, malaise, and jaundice, while GBS presented with muscle weakness and areflexia. Laboratory findings showed albuminocytological dissociation in 76.2 % of cases. Nerve conduction studies predominantly indicated AIDP subtype (32/46, 69.6 %). Treatment involved IVIG, plasmapheresis, and supportive care, with recovery times ranging from one week to 18 months. One fatality was reported.

Conclusions

This review suggests a potential link between HAV infection and GBS, proposing a mechanism: molecular mimicry. It emphasizes the need for increased awareness and preventive measures, especially in areas with lower health standards. However, further research is needed to clarify the possible mechanisms and deepen our understanding.

Sequential administration of efgartigimod shortened the course of Guillain-Barré syndrome: a case series

Guillain-Barré syndrome (GBS) is a serious neurological condition with limited treatment options. A recent report demonstrated successful treatment with efgartigimod alone in two patients with GBS, although it did not significantly shorten the disease duration. This case series investigates the effects of sequential efgartigimod administration in patients with different GBS phenotypes and varying levels of disease severity. All three patients tested positive for immunoglobulin G (IgG) antibodies against serum gangliosides. In Case 1, the patient was treated with 0.4 g/kg of intravenous immunoglobulin (IVIg) for 5 days, showing minimal recovery. After receiving 3 weekly doses of efgartigimod (10 mg/kg), the patient achieved independent ambulation 19 days post-onset, with a reduction in serum ganglioside antibody titers and total IgG levels. Case 2 involved a middle-aged man with Miller Fisher syndrome (MFS)-GBS overlap, who experienced worsened autonomic dysfunction following IVIg treatment. After three doses of efgartigimod, the patient showed symptom improvement within 1 month, alongside a reduction in IgG antibody levels. In Case 3, a 27-year-old male with MFS-GBS overlap, initially unresponsive to IVIg, showed significant improvement in ophthalmoplegia following two doses of efgartigimod, with his serum ganglioside antibodies eventually becoming undetectable. Our findings suggest that sequential efgartigimod treatment may effectively reduce serum anti-ganglioside antibody titers and potentially shorten the disease course in severe GBS and MFS-GBS overlap syndrome. Additionally, it may offer clinical benefits for patients with GBS who have a poor or no response to IVIg, particularly in treating ophthalmoplegia.

Guillain-Barré syndrome during the COVID-19 era: A nationwide study of hospitalized cases in South Korea

This study aimed to analyze the trends and characteristics of hospitalized Guillain-Barré syndrome (GBS) incidence and management in South Korea before and during the coronavirus disease 2019 pandemic, assessing potential impacts of nonpharmaceutical interventions and shifts in public health dynamics. We conducted a retrospective analysis using data from the Health Insurance Review and Assessment Service database from 2013 to 2021, divided into prepandemic (2013-2019) and pandemic (2020-2021) periods. Incident GBS cases were identified based on the G61.0 code with hospital admissions. A total of 10,596 hospitalized patients with GBS were identified, with 8537 cases in the prepandemic period and 2059 during the pandemic. While the overall GBS incidence did not show a statistically significant change during the pandemic (P = .056), the mean age of patients increased. Notably, a significant rise in the proportion of patients receiving intravenous immunoglobulin was observed during the pandemic (P < .001), with older patients showing higher mean ages (P = .007). However, the proportion of patients requiring mechanical ventilation remained stable (P = .240). The findings suggest that while hospitalized GBS incidence remained stable amidst the pandemic and reduced respiratory infection admissions, the increase in intravenous immunoglobulin use points to more severe presentations, particularly among older patients. This highlights the multifactorial nature of GBS triggers and the need for continued investigation into how evolving public health measures and infectious disease patterns influence GBS incidence and management.

Clinical Application of Phage Immunoprecipitation Sequencing to Diagnose Enterovirus D68 as the Underlying Etiology in a Case of Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is an acute peripheral neuropathy often preceded by respiratory or gastrointestinal infections, though molecular testing of cerebrospinal fluid is often inconclusive. In a recent case of severe pediatric GBS in British Columbia, Canada, we detected cerebrospinal fluid antibodies against enterovirus D to link GBS with prior enterovirus D68 respiratory infection.

Prevalence and molecular characterization of Campylobacter spp. isolated from chicken, beef, pork and sheep livers at Irish abattoirs

Thermotolerant Campylobacter spp. are the leading causes of food-borne diarrhoea in humans with most cases attributed to C. jejuni, and C. coli. Although chicken meat is considered the main source of infection in humans, the significance of other sources for campylobacteriosis in humans is less understood. The objective of this study was to determine the prevalence of thermotolerant Campylobacter spp. in chicken, beef, pork, and sheep liver in Ireland and to carry out whole genome sequencing (WGS) on the resulting isolates to characterize them molecularly. In addition, genome sequences of Irish clinical isolates were downloaded from the National Center for Biotechnology Information (NCBI) and compared with sequences from this study. The prevalence of Campylobacter spp. in chicken, beef, pork and sheep liver was 70 %, 4.4 %, 16 % and 80.0 %, respectively. Chi-Squared analysis indicated that the statistical differences in positivity rates between the four species were significant (P < 0.001). Amongst the 81 (43 %) positive liver samples, speciation revealed an overall predominance of C. jejuni (62 %), followed by C. coli (48 %) and C. lari (1 %) in all meat types except pork. Nine (11 %) samples were confirmed positive for more than one Campylobacter species with five of these nine samples recovered from sheep livers. Following analysis of WGS data, a wide range of diversity was observed and where clusters were identified, all were confined to the same animal species. No AMR genes were identified in the C. lari isolate, while C. jejuni and C. coli isolates were found to harbour resistance genes for tetracyclines, beta-lactams, aminoglycosides, and quinolones. Two clusters were identified between isolates from this study and human clinical data and the most prevalent clonal complex was CC-21, identified in this study and in clinical isolates. These results highlight the role of liver as a potential source of human Campylobacter infection. The significance of liver as a vehicle of human campylobacteriosis needs to be examined further particularly in respect to ovine sources.

Can patient self-evaluation of functional status be used for evaluation of impairment of motor function in Guillain-Barré syndrome? Mapping clinician- and patient-reported outcomes in a phase 3 study of eculizumab in Japan

Background and purpose

Guillain-Barré syndrome (GBS) is an autoimmune neurological disorder characterized by muscle weakness. In clinical trials, treatment benefit and disease severity are typically measured using clinician-reported outcome measures like the Hughes Functional Grading Scale (HFGS). However, patient-reported outcome measures, such as the Rasch-built Overall Disability Scale (R-ODS) may provide additional insight into the patient experience during treatment. In this study, exploratory analyses of clinical trial data were performed to investigate how existing clinician-reported outcomes and patient-reported outcomes can help to assess disease progression by providing an accurate measurement of functional status.

Methods

Data were collected as part of a phase 3 study to assess the safety and efficacy of eculizumab in patients in Japan with severe GBS. The association between HFGS score and R-ODS total centile score (linear measure of limitations; 0, most severe activity and social participation limitations and 100, no limitations) was assessed using the Spearman rank-order correlation coefficient. Threshold values of R-ODS total centile score that could differentiate between patients with an HFGS score of ≤ 1 and > 1 were determined using receiver-operating characteristic curve analyses and mapping (Rasch measurement theory). A triangulation approach was used to establish a proposed value for R-ODS total centile score equivalent to an HFGS score of ≤ 1 or > 1.

Results

Overall, 57 patients were included in this analysis. These exploratory analyses revealed good correlation between R-ODS total centile and HFGS scores. Using the Rasch model, mapping of HFGS to R-ODS scores showed a good fit. Evaluation of the R-ODS threshold that could approximate the functional motor symptom categories based on HFGS (score of 0 or 1) revealed a range of values from 60 to 80. Based on a trial sample, a threshold of 60 was found to have 100% sensitivity and 87% specificity at week 4, and 93.8% sensitivity and 77.8% specificity at week 24.

Conclusion

This study established thresholds for the R-ODS total centile score that could approximate classification of functional impairment in GBS based on the HFGS score. Given that the R-ODS reflects the patient perspective, it may be used to capture a more complete picture of GBS severity.

Immunoglobulin unresponsive Guillain-Barré syndrome: rinse or repeat? A systematic review

Introduction

Severe Guillain-Barré syndrome (GBS) patients may not show improvement after a single course of intravenous immunoglobulin (IVIg) therapy. Current treatment options include either a second course of IVIg or therapeutic plasma exchange (TPE). This systematic review aims to evaluate the current literature on the use of a second course of IVIg or TPE in patients who fail to show clinical improvement after the first IVIg course.

Methods

We searched PubMed, Embase and Medline databases up until 26 October 2023. Studies that evaluated adult patients with confirmed GBS who have failed one full course of IVIg and subsequently received either repeat IVIg or TPE were included. Risk of bias was performed using study-specific checklists. A narrative synthesis of results is presented.

Results

A total of 37 articles were identified (1 randomised controlled trial (RCT), 3 observational and 33 case reports/series), consisting of 422 patients in total. 12 studies evaluated repeat IVIg and 24 studies evaluated TPE after IVIg. There was no superiority of a repeat course of IVIg or TPE in all clinical outcome measures.

Conclusions

The evidence suggests with a low degree of certainty that there is no beneficial effect of further IVIg in unresponsive GBS. The quality of evidence regarding TPE after IVIg is insufficient to suggest any efficacy due to a lack of RCTs. We recommend standardised case reporting with consideration for a multinational case registry and RCTs to determine the efficacy of TPE after initial IVIg unresponsiveness.

Clinical implications of human Parvovirus B19 infection on autoimmunity and autoimmune diseases

Parvovirus B19 (B19V) is a human pathogen from the Parvoviridae family that primarily targets and replicates in erythroid progenitor cells (EPCs). While its symptoms are typically self-limiting in healthy individuals, B19V can cause or exacerbate autoimmune diseases in vulnerable patients. This review integrates the involvement of B19V in the development and worsening of several autoimmune diseases, including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), hematological disorders (thalassemia, anemia, and thrombocytopenia), vasculitis, antiphospholipid syndrome (APS), dermatological disease (systemic sclerosis, psoriasis), autoimmune thyroid disease, myocarditis, and myasthenia gravis, and autoinflammatory disease of adult-onset Still's disease (AOSD). B19V contributes to autoimmunity and autoimmune disease onset and progression through mechanisms such as molecular mimicry, immune system disruption, and chronic infection. By summarizing findings from in vitro experiments, clinical case studies, seroprevalence data, and biopsy results, this review highlights the critical connection between B19V and autoimmune disease development. Recognizing the role of B19V in the early diagnosis and management of these conditions is essential, as its presence may influence the disease course and severity. Greater awareness among healthcare professionals and the public is necessary to address the impact of B19V, leading to more accurate diagnoses and better-informed treatment approaches for autoimmune diseases linked to the virus.

Campylobacter molothri sp. nov. isolated from wild birds

Twenty-nine hippuricase-positive Campylobacter strains were isolated from wild birds and river water. Previous characterization using atpA typing indicated that these strains were related to Campylobacter jejuni and Campylobacter coli but were most similar to three recently described hippuricase-positive Campylobacter species recovered from zebra finches, i.e. C. aviculae, C. estrildidarum and C. taeniopygiae. Phylogenetic analyses using 330 core genes placed the 29 strains into a clade well separated from the other Campylobacter taxa, indicating that these strains represent a novel Campylobacter species. Pairwise digital DNA-DNA hybridization and average nucleotide identity values were below 70 and 95 %, respectively, thus providing further supporting evidence of a novel taxon. Standard phenotypic testing was performed. All strains are microaerobic or anaerobic, motile, Gram-negative, spiral cells that are oxidase, catalase and nitrate reductase positive, but urease negative. Genomic analyses indicate that the 29 strains can potentially synthesize very few amino acids de novo and are auxotrophic for many amino acids and cofactors, similar to the species composing the Campylobacter lari group. In addition, these strains encode complete Entner-Doudoroff and Leloir pathways, suggesting that they may possess the ability to utilize both glucose and galactose; these pathways were also identified in the genomes of the zebra finch-associated taxa. The data presented here show that these strains represent a novel species within Campylobacter, for which the name Campylobacter molothri sp. nov. (type strain RM10537T=LMG 32306T=CCUG 75331T) is proposed.

Neurological Mystery Post Travel: An Atypical Presentation and Partial Recovery With Immunotherapy

This case highlights the diagnostic challenges in atypical neurological presentations and the role of empirical immunotherapy despite the absence of a definitive diagnosis. We present a South Indian woman in her 40s who developed progressive lower limb weakness and respiratory compromise after recent international travel. Initially suspected to have Guillain-Barré syndrome (GBS), extensive investigations, including electromyography (EMG), nerve conduction studies (NCS), and cerebrospinal fluid (CSF) analysis, failed to confirm a clear diagnosis. Despite this uncertainty, empirical intravenous immunoglobulin (IVIG) therapy resulted in clinical improvement, supporting the likelihood of an immune-mediated process. Notably, the patient had been experiencing an ongoing flare-up of vitiligo, an autoimmune disease characterized by immune-mediated destruction of melanocytes, for approximately six months leading up to and during the onset of neurological symptoms, suggesting heightened autoimmune activity around the period of symptom onset. Additionally, the patient's South Indian ethnicity is relevant, as autoimmune disorders, including neurological conditions, may have distinct presentations and prevalence among South Asian populations due to genetic and environmental factors. The patient's prolonged ICU stay, need for mechanical ventilation, and complications such as stridor and vocal cord dysfunction underscore the complexity of managing undifferentiated neurological cases. This case serves as an important educational tool, demonstrating the limitations of standard diagnostic criteria in rare or evolving neurological syndromes, the importance of empirical immunotherapy in suspected immune-mediated conditions, and the need for a multidisciplinary approach with careful follow-up. By highlighting the intersection between neurology, immunology, and critical care, this case reinforces the importance of clinical judgment and individualized treatment strategies when conventional diagnostics fall short.

The overlap of diabetic and inflammatory neuropathies: Epidemiology, possible mechanisms, and treatment implications

Diabetic polyneuropathy is the common neuropathy of diabetes. However, several inflammatory neuropathies may occur during diabetes. Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) represents the most treatable example. There has been uncertainty about a higher risk of CIDP in subjects with diabetes. Contradicting earlier reports, subsequent epidemiological studies failed to confirm an association. However, more recent studies from different populations have shown a two-fold relative risk of concurrent diabetes with CIDP. Recognition of CIDP is important in diabetes as treatment response rates have been reported as comparable with or without diabetes. However, with diabetes, the clinical presentation of CIDP and the resulting disability may be more severe due to additional axonal loss from pre-existing diabetic polyneuropathy and delayed diagnosis. An association of nodo-paranodopathy has similarly been described with a three-fold relative risk of concurrent diabetes in seropositive subjects, particularly those harbouring anti-contactin 1 antibodies. Although rare, recognition of nodo-paranodopathy, with characteristic clinical features, in the context of diabetes is likewise important in view of treatment implications. Other inflammatory neuropathies in diabetes are the painful or painless, cervical, or lumbar, radiculoplexus neuropathies. These need distinguishing from variant, multifocal forms of CIDP, as are not treatable, although remit spontaneously over months or years. There are reports of possible association of Guillain-Barré syndrome (GBS), and particularly of greater GBS severity, with diabetes. Finally, vasculitic neuropathy may also occur in diabetes and requires early suspicion, urgent investigations and immunosuppressant treatment. As the worldwide prevalence of diabetes rises, prompt recognition of its concurrent inflammatory neuropathies, is essential.

Antibody Responses to EBV and Toxoplasma and Their Genetic Links to Guillain-Barré Syndrome: A Mendelian Randomization Study

BACKGROUND

This study aims to investigate the potential causal relationship between antibody-mediated immune responses to infectious agents and Guillain-Barré syndrome (GBS) using a two-sample Mendelian randomization (MR) approach.

METHODS

Publicly available summary data from genome-wide association studies (GWAS) were utilized for comprehensive analysis. A genome-wide and human leukocyte antigen association study conducted by Guillaume Butler-Laporte et al. (n = 9724) examined 46 types of antibody-mediated immune responses. GWAS summary statistics for GBS were obtained from the FinnGen consortium (n = 215,931) comprising European populations. The primary method for MR analysis was the inverse-variance weighted (IVW) method. Various sensitivity analyses were conducted to assess the heterogeneity and pleiotropy of the findings.

RESULTS

The IVW method indicates a negative correlation between elevated levels of Epstein-Barr virus (EBV) viral capsid antigen (VCA) p18 antibody and the risk of GBS (OR = 0.79, 95% confidence interval [CI]: 0.65-1.85, p = 0.012). Elevated levels of Toxoplasma gondii surface antigen 1 (sag1) antibody also show a negative correlation with the risk of GBS (OR = 0.79, 95% CI: 0.67-0.92, p = 0.003). No evidence of heterogeneity or horizontal pleiotropy was found in the MR analysis.

CONCLUSIONS

Elevated levels of EBV VCA p18 and T. gondii sag1 antibodies appear to be negatively correlated with the risk of GBS, suggesting that immune responses to these pathogens may play a protective role. However, the CI for the EBV VCA p18 association includes 1, indicating the need for caution in interpreting this result. Further research, including mechanistic studies and broader immune profiling, is needed to confirm these findings and explore the underlying pathways.

Guillain-Barré Syndrome Initially Perceived as Unilateral Facial Palsy in Epstein-Barr Virus Infection

We encountered a case of a 21-year-old female presenting with unilateral peripheral facial nerve palsy, initially suspected to be triggered by Epstein-Barr virus (EBV) infection. The patient initially complained of numbness in both lower extremities, progressing to difficulty with mobility by day two, leading to emergency admission. Despite an initial evaluation by a neurologist in the emergency department, Guillain-Barré Syndrome (GBS) was not diagnosed, and she was admitted to internal medicine for further investigation. During hospitalization, she developed infectious mononucleosis and left-sided facial nerve palsy, prompting a referral to our otolaryngology department. Upon further evaluation, subtle weakness on the contralateral side was noted, raising suspicion of bilateral facial nerve palsy. Eventually, the case was diagnosed as bilateral facial nerve palsy associated with GBS. This case underscores the crucial role of otolaryngologists in raising suspicion for GBS when bilateral facial nerve involvement is considered. Recognizing bilateral facial nerve palsy is essential for correctly diagnosing GBS. Since bilateral facial nerve palsy can be subtle, a lack of facial expression may serve as an early diagnostic clue. Additionally, it is important to understand the association between infectious mononucleosis and GBS, as infectious mononucleosis is a common condition. This relationship will be explored in detail.

Management of mechanical ventilation and weaning in critically ill patients with neuromuscular disorders

PURPOSE

Myasthenia-gravis and Guillain-Barre-syndrome are two of the most common causes of acute and reversible neuromuscular-respiratory-failure(ARNRF), both may worsen respiratory-failure and need for invasive-mechanical-ventilation(IMV) for long-periods due to muscle-weakness. However, approitive IMV-mode for ARNRF patients that better gas-exchange and weaning in ARNRF remain unclear.

MATERIALS AND METHODS

Critically-ill-patiens with IMV due to ARNRF, who could meet the weaning-criterias (after intubation for more than 7-days; difficult-weaning), between 2013, and 2023 were included in the study. IMV-settings, simultaneous arterial-blood-gas (ABG) analyses, and prognosis were recorded for each patient on relevant days.

RESULTS

Sixty-critically-ill-patients with ARNRF who defined as difficult-weaning were included in the study. When different IMV-modes were used in the same patient, simultaneous ABG results were compared for each ventilation-mode. It was determined that the partial-pressure-of-oxygen/fraction of inspired-oxygen-ratios were significantly higher and partial-carbon-dioxide-levels were significantly lower when critically-ill-patients were ventilated with the biphasic-positive-airway-pressure-ventilation(BIPAP) (95 % CI: [0.641-1.41]; p < .001; 95 % CI: [-1.05-.351]; p < .001, respectively). Length-of-time-until-weaning was significantly shorter in BIPAP-mode for each patient in the study group(95 % CI: [0.717-0.188]; p < .001). Moreover, weaning-success was statistically higher in patients with ARNRF were ventilated with BIPAP one-week-before spontenous-breathing-trial (95 % CI [1.026-21.65]; p = .046) than with all other IMV-modes.

CONCLUSION

According to our findings, when BIPAP was selected as the IMV-settings, gas exchange was improved,and weaning-success was higher in critically-ill-patients with ARNRF.

Association of dysautonomia and different risk factors in patients with Guillain-Barré syndrome in a tertiary hospital in the Philippines

BACKGROUND

Guillain-Barré syndrome (GBS) presents with progressive ascending weakness, but it can also present with dysautonomia such as tachycardia, blood pressure fluctuations, diaphoresis, ileus, and urinary retention. GBS patients with dysautonomia was observed to have longer hospital stays and higher mortality rates than those without dysautonomia. We aimed to determine the risk factors for dysautonomia and its manifestations among patients with GBS and compared their features to those without dysautonomia.

METHODS

We conducted a 10 year-retrospective review of GBS patients admitted at the Philippine General Hospital. The patient demographics, comorbidities, GBS disability status scale (GBS-DS), GBS variants, parameters of dysautonomia, treatment, and outcome were recorded and analyzed. Simple and multiple logistic regression analysis were conducted to determine the factors associated with dysautonomia and the relationships were expressed using odds ratio.

RESULTS

71 patients were included, and 49% developed dysautonomia. Hypertension and tachycardia were the most prominent manifestations. There was an increase in the odds of developing dysautonomia in a one-year increase in age (OR: 1.11, p = 0.001) and a point increase in GBS-DS (OR:1.65, p = 0.037) during admission. Pre-morbid hypertension (OR:0.13, p = 0.028) and alcoholism (OR: 0.17, p = 0.037) are shown to decrease the odds of developing dysautonomia. Although GBS patients with dysautonomia had longer hospital stay (12.33 days), it only predicts 5.5% of the variability.

DISCUSSIONS

The prevalence of cardiovascular manifestations was postulated from cardiosympathetic hyperactivity between arterial baroreceptors, cardiac parasympathetic fibers, and preganglionic sympathetic vasomotor fibers. The protective mechanism of premorbid hypertension could be attributed to the prior intake of antihypertensive medications, which mitigate cardiosympathetic fluctuations, while the protective effect of alcoholism needs to be further studied.

CONCLUSION

Patients who are older and with a high GBS-DS on admission, prompt close monitoring for the development of dysautonomia. The protective effects of premorbid hypertension and alcoholism needs further evaluation. The odds of developing pneumonia and being on a mechanical ventilator, while not statistically significant, could contribute to longer hospital stay of patients with dysautonomia. A larger prospective study is warranted to confirm these results.

Traditional herbal medicine for Guillain-Barré syndrome: A systematic review and meta-analysis

Background

Guillain-Barré syndrome (GBS) is a rapid-onset disease caused by the immune system damaging the peripheral nervous system. Since most standardized treatments for GBS focus on acute phase treatment, there are limitations to the rehabilitation and management of general conditions. In East Asian countries, herbal medicine has been used to treat GBS and aid rehabilitation. Therefore, herbal medicine is considered a complementary treatment for GBS. Hence, the present study was conducted to investigate the clinical evidence of herbal medicine treatment for GBS and to provide a research strategy for the future.

Method

PubMed, Embase, Cochrane, CNKI, CiNii, and Science ON were searched from inception to December 4, 2024. Randomized controlled trials (RCTs) comparing conventional Western medicine (CWM) combined with herbal medicine (treatment group) and only CWM (control group), to evaluate the effects of herbal medicine combined with CWM as a treatment for GBS were included. All bibliographic data from the collected studies were summarized in Endnote X9 (Clarivate Analytics). The meta-analysis was conducted using Review Manager (Revman) 5.4.1. software. Effectiveness was assessed by Total Effective Rate (TER), Modified Barthel Index (mBI) score and Manual Muscle Testing (MMT) score. Safety was evaluated as the occurrence of a significant adverse events (AEs).

Results

Ten RCTs that comprised 764 participants were included. Based on the meta-analysis, TER was found to significantly improve in the treatment group compared with the control group (risk ratios: 1.14, 95 % confidence interval: 1.09 to 1.20, p < 0.00001). The mBI score and MMT score of upper limb and lower limb also significantly improved in the treatment group compared with the control group. No significant AEs were reported in any included study.

Conclusions

The results of this study suggest that the combination of CWM and herbal medicine may be a better and safer method of physical function recovery and rehabilitation in patients with GBS. Further qualified studies are required to establish this hypothesis.

Diaphragm dysfunction: how to diagnose and how to treat?

The diaphragm, crucial for respiratory function, is susceptible to dysfunction due to various pathologies that can affect the nervous system, neuromuscular junction or the muscle itself. Diaphragmatic dysfunction presents with symptoms ranging from exertional dyspnoea to respiratory failure, significantly impacting patients' quality of life. Diagnosis involves clinical evaluation complemented by imaging and pulmonary function tests. Chest radiography, fluoroscopy, and ultrasonography are pivotal in assessing diaphragmatic movement and excursion, offering varying sensitivities and specificities based on the type and severity of dysfunction. Ultrasonography emerges as a noninvasive bedside tool with high sensitivity and specificity, measuring diaphragm thickness, thickening fraction, and excursion, and enabling monitoring of disease progression and response to treatment over time. Treatment strategies depend on the underlying aetiology and severity, ranging from conservative management to interventions such as surgical plication or diaphragmatic pacing. Ventilatory support, particularly noninvasive ventilation, plays a pivotal role in treatment, enhancing lung function and patient outcomes across unilateral and bilateral dysfunction. Despite advances in diagnostic techniques, awareness and systematic evaluation of diaphragmatic function remain inconsistent across clinical settings. This review consolidates the current understanding of diaphragmatic dysfunction, highlighting diagnostic modalities and treatment options to facilitate early recognition and management of this entity.

Numbness on the Medical Take: An Atypical Presentation of Guillain-Barre Syndrome With Unilateral Paraesthesia and Rapid Progression to Bulbar Palsy: A Case Report

Guillain-Barré syndrome (GBS) is characterized classically by progressive and symmetrical motor weakness and areflexia. We describe a case of GBS with initially preserved reflexes and power, leading to delayed diagnosis, who latterly required urgent ventilator support and plasmapharesis to highlight the importance of considering atypical presentations of this common condition.

Anti-sulfatide antibody-positive Guillain-Barré syndrome in adults following off-craniotomy for cerebellar contusion: A case report

RATIONALE

Gullain-Barré syndrome (GBS) is a rare autoimmune condition primarily presenting with symmetrical progressive limb weakness. It is frequently associated with sensory and autonomic symptoms and autonomic disturbances and often manifests seropositivity for anti-ganglioside antibodies. Infections are considered major precipitants; however, GBS post-craniotomy for severe traumatic brain injury is a rarity.

PATIENT CONCERNS

A 79-year-old female underwent craniotomy for a cerebellar contusion sustained from severe traumatic brain injury, leading to quadriplegia, autonomic dysfunction, dilated pupils, and respiratory failure. However, the patient's GBS manifested slightly differently. Her limb weakness was asymmetric and progressed from 1 upper limb to the other.

DIAGNOSES

The diagnosis of GBS was confirmed based on clinical presentation, cerebrospinal fluid analysis showing albuminocytologic dissociation, and the detection of anti-sulfatide antibodies in serum.

INTERVENTIONS

The patient received intravenous immunoglobulin (IVIG) therapy at 2 g/kg daily, along with supportive measures including mechanical ventilation and rehabilitation.

OUTCOMES

The patient demonstrated significant improvement within 5 days of IVIG treatment, achieving near-complete functional recovery with grade 4 muscle strength at discharge 6 weeks post-intervention.

LESSONS

This case highlights the need to consider GBS in postoperative patients with acute limb weakness, even in atypical presentations. Early recognition and timely IVIG treatment are critical for favorable outcomes.

Management of severe pediatric Guillain-Barré syndrome in a low-income country: efficacy and safety of therapeutic plasma exchange in pediatric patients: a retrospective study

BACKGROUND

Guillain-Barré syndrome (GBS) is an autoimmune disease that affects the peripheral nervous system leading to motor, sensory, and sometimes autonomic manifestations. Therapeutic plasma exchange (TPE), which involves the selective removal of pathological molecules, such as auto-antibodies, from plasma, has proven to be safe and effective in adults with GBS. However, its application in pediatric patients lacks sufficient evidence. This study aims to evaluate the efficacy and safety of TPE in pediatric patients with severe GBS, in a low-resource setting.

METHODS

This is a single-center retrospective study of 36 GBS patients aged between 2 and 13 years. A total of 122 TPE sessions were administered, with a median of four sessions per patient. A human albumin solution was the exchange fluid in all the sessions. Clinical improvement was evaluated through general examination and muscle power assessment using the Medical Research Council (MRC) scale.

RESULTS

All patients showed clinical improvement upon treatment with TPE. The grade of power in the upper extremities increased from a mean of 1.7 ± 1.1 at the peak of illness to 3.7 ± 0.9 at discharge, indicating an increase of 2.0 ± 1.1 (95% CI, 1.6 to 2.4, p< 0.001). Alternatively, in the lower extremities, it increased from 1.2 ± 1.1 to 2.5 ± 0.8, indicating a significant rise of 1.4 ± 0.8 (95% CI, 1.1 to 1.6, p< 0.001). There was a significant improvement in the cranial, autonomic, and respiratory functions among all patients. Half of the patients were available for follow-up and showed full recovery, with six of them still exhibiting minimal residual deficits. TPE-related complications were mostly mild or moderate, with tachycardia, hypotension, and mild anemia being the most common. However, serious complications occurred in three of the patients, necessitating the discontinuation of the treatment in two of them. There was no mortality related to TPE in this study.

CONCLUSIONS

TPE shows promise in treating pediatric GBS. In this study, TPE was associated with the recovery of neurological functions, yielding positive outcomes with only minimal residual deficits. However, balancing its benefits with potential risks requires careful clinical judgment and rigorous monitoring to ensure patient safety and optimize outcomes. TPE was a more cost-effective and accessible option than IVIG in this financially restricted, low-income setting.

Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a rare immune-mediated polyradiculoneuropathy. Patients typically develop rapidly progressive weakness and sensory deficits that can result in complete paralysis requiring mechanical ventilation. GBS is usually a monophasic disease in which an aberrant immune response to an infection or other trigger damages the peripheral nerves. For example, in patients with preceding Campylobacter jejuni infection, molecular mimicry causes a cross-reactive antibody response to nerve gangliosides. Diagnosis is based on clinical features, supported by cerebrospinal fluid analysis and nerve conduction studies. Effective treatments include plasma exchange and intravenous immunoglobulins. However, ~20% of patients who received treatment are unable to walk after 6 months and ~5% die as a consequence of GBS. Important knowledge gaps in GBS include its pathogenesis, especially after viral infections. In addition, there is a lack of specific biomarkers to improve the diagnosis, monitor the disease activity, and predict the clinical course and outcome of GBS. Major challenges for the future include finding more effective and personalized treatments, which are affordable in low-income and middle-income countries, and preparation for outbreaks of infections as potential triggers for GBS.

Risk factors of disease severity and mechanical ventilation requirement in childhood Guillain-Barré Syndrome

BACKGROUND

This study aimed to investigate the risk factors associated with the severity of the disease, the need for mechanical ventilation (MV) and poor prognosis in the early stages of Guillain-Barré Syndrome (GBS).

METHODS

Data of children who met GBS diagnostic criteria were evaluated retrospectively. The sample was divided into three binary subgroups according to severe GBS (Hughes Functional Grading Scale [HFGS] ≥ 4 at admission), mechanical ventilation (MV) requirement, and poor prognosis (inability to walk independently, HFGS ≥ 3 after six months). Various clinical, laboratory and electrophysiological parameters were compared between these subgroups.

RESULTS

The mean age of 63 children with GBS was 91.55±49.09 months. 13 (20.6%) patients required MV and 4 (6.3%) patients died. Associated risk factors for the need for MV in severe GBS were found to be autonomic dysfunction, bulbar palsy, sensory impairment, lowest total Medical Research Council (MRC) scale for muscle strength score at admission, high modified Erasmus GBS respiratory failure score (mEGRIS), high neutrophil-lymphocyte ratios (NLR) and high systemic immune-inflammation index (SII) values (p<0.001, p=0.003, p=0.033, p<0.001, p<0.001, p=0.037 and p=0.042, respectively). The lowest total MRC scale for muscle strength score at admission was a significant indicator of poor prognosis (p<0.001).

CONCLUSIONS

Autonomic dysfunction, bulbar palsy, sensory impairment, lowest total MRC scale for muscle strength score at admission, high mEGRIS score, high NLR and SII values are potential risk factors for the need for MV in children with severe GBS. The lowest total MRC scale for muscle strength score at admission was associated with poor prognosis.

Human parvovirus B19 as an unusual cause of Guillain-Barré syndrome: A case report

Human Parvovirus B19 (B19V) is rarely observed in patients with Guillain-Barré syndrome. We report the case of a patient with rapidly progressive functional impotence of the limbs. B19V was detected in both blood and CSF samples. The patient improved clinically after plasma exchanges, but mild functional impotence persisted 2 months later.

Pain determinants and quality of life in Guillain-Barre syndrome: a prospective cohort study

Background

Pain is a serious manifestation in both the acute and chronic stages of Guillain-Barre syndrome (GBS). We evaluated the frequency, characteristics and associated factors of pain and its impact on quality of life (QoL) among patients with GBS.

Methods

We enrolled 644 patients with GBS from prospective cohort studies in Bangladesh conducted between 2010 and 2024. Data were collected at enrolment and at standard follow-up time points up to 26 weeks. Pain intensity was measured by a pain numeric rating scale. Group differences were tested using the χ² or Fisher's exact test, longitudinal changes were analysed with repeated-measures analysis of variance and correlations were analysed with Spearman's rank test.

Results

The median age of the patients was 31 years, with 70% men. During enrolment, 71% of patients reported pain, which persisted among 38% at week 13 and 26% at week 26. Pain was significantly associated with disease severity, muscle weakness and treatment with intravenous immunoglobulin in both the acute and chronic stages. Patients with acute pain had a higher proportion of axonal GBS (p=0.000) than those without pain. Chronic pain was associated with higher age (p=0.006), male sex (p=0.000), preceding diarrhoea (p=0.033) and dysautonomia (p=0.000). Higher pain intensity was reported among women (p=0.027), patients with higher age (p=0.029) and severe form of GBS (p=0.038) compared with counter groups. Acute pain was significantly associated with the 'self-care' (p=0.023), 'usual activities' (p=0.049) and 'anxiety/depression' (p=0.048) domains of QoL, whereas chronic pain was associated with the 'anxiety/depression' (p=0.005) domain.

Conclusions

Pain presented as a serious symptom negatively affecting the QoL in GBS. Systematic evaluation of pain is recommended to ensure a personalised treatment approach for GBS.

Comprehensive analysis of the global impact and distribution of tick paralysis, a deadly neurological yet fully reversible condition

SUMMARYTick paralysis is a potentially fatal condition caused by neurotoxins secreted by the salivary glands of certain ticks. Documented cases have been reported worldwide, predominantly in the United States, Canada, and Australia, with additional reports from Europe and Africa. This condition also affects animals, leading to significant economic losses and adverse impacts on animal health and welfare. To date, 75 tick species, mostly hard ticks, have been identified as capable of causing this life-threatening condition. Due to symptom overlap with other conditions, accurate diagnosis of tick paralysis is crucial to avoid misdiagnosis, which could result in adverse patient outcomes. This review provides a comprehensive analysis of the current literature on tick paralysis, including the implicated tick species, global distribution, tick toxins, molecular pathogenesis, clinical manifestations, diagnosis, treatment, control, and prevention. Enhancing awareness among medical and veterinary professionals is critical for improving the management of tick paralysis and its health impacts on both humans and animals.

Epidemiological and Genomic Characterization of a Campylobacter jejuni Outbreak in Lishui, China

Campylobacter is one of the leading causes of bacterial foodborne diarrheal diseases throughout the world. Reported outbreaks of Campylobacter are infrequent in China. This article described such an outbreak among students from a junior high school in East China during November 2019. A total of 40 samples were collected as follows: 24 stool samples from patients, 12 stool samples from kitchen staff members, and 4 water samples from cafeteria. The stool samples were tested for the presence of Salmonella, enterotoxigenic Escherichia coli, Shigella, Vibrio parahaemolyticus, Vibrio cholera, Listeria monocytogenes, Staphylococcus aureus, Yersinia enterocolitica, Bacillus cereus, Clostridium perfringens, norovirus, rotavirus, adenovirus, astrovirus, and sapovirus by real-time polymerase chain reaction (PCR). Pulsed-field gel electrophoresis (PFGE), next-generation sequencing, and antimicrobial susceptibility testing were performed to determine the relatedness of the Campylobacter jejuni isolates in this outbreak. Forty-seven cases were reported with diarrhea among 569 seventh grade students and staff. In these 47 cases, we detected that C. jejuni through real-time PCR in 16 fecal samples was positive, whereas the remaining fecal samples were tested negative by real-time PCR. Only three C. jejuni strains were isolated from stool samples of case patients, and all of them showed 100% PFGE similarity to strain ST6913. Whole genome sequencing analysis revealed no single nucleotide variation in the three isolates. This is one of the few reports in China about outbreak caused by C. jejuni. C. jejuni ST6913 was responsible for this outbreak.

Resolution of acute motor axonal neuropathy in a patient after treatment with efgartigimod: A case report

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute autoimmune neuropathy characterized by progressive muscle weakness, often caused by immunoglobulin G (IgG) autoantibodies. There are several subtypes of GBS, of which acute motor axonal neuropathy (AMAN) is one of the most severe subtypes associated with axonal damage. It is well known that the current clinical standard of treatment is intravenous immunoglobulin (IVIg) and plasma exchange (PLEX), but some patients often show limited response or experience persistent disability. Efgartigimod, an Fc fragment of human IgG antibody, provides a way to target and reduce pathogenic IgG antibodies as a natural ligand Fc receptor (FcRn). The purpose of this study was to observe the therapeutic effect of efgartigimod on axonal GBS, which is expected to be a potential therapeutic method for GBS and AMAN.

METHODS

We present a case of a 58-year-old man diagnosed with AMAN, presenting with ascending symmetrical limb weakness, flaccid paralysis, and multiple cranial nerve palsies. Electromyography confirmed the axonal subtype of GBS. Despite receiving IVIg and PLEX, the patient showed suboptimal recovery. Subsequently, he was treated with efgartigimod at a dose of 10 mg/kg weekly for 4 weeks, demonstrating significant improvement in both clinical symptoms and electromyographic findings, with good tolerability.

RESULT

This case highlights the potential efficacy and safety of a 4-dose efgart-igimod regimen in AMAN, particularly for patients with inadequate response to conventional therapies. By targeting FcRn and promoting IgG degradation, efgartigimod offers a novel mechanism to modulate the aberrant immune response underlying AMAN.

CONCLUSION

Efgartigimod at a dose of 10 mg/kg weekly for 4 weeks demonstrated promising results in this case of AMAN. While further research is warranted, our findings suggest that efgartigimod may represent a valuable addition to the therapeutic armamentarium for AMAN and potentially other autoimmune neurological conditions. Well-designed clinical trials are crucial to confirm these findings and establish optimal treatment protocols for efgartigimod in AMAN.

A rare association of Guillain-Barré syndrome/Miller-Fisher syndrome overlap syndrome and Herpes Simplex Virus Type 1 infection: trigger or exacerbating factor?

Guillain-Barré syndrome (GBS) and its variants represent a spectrum of acute, immune-mediated polyneuropathies with heterogeneous clinical presentations and underlying etiologies. While infectious triggers are common precursors to these disorders, the association between viral infections and autoimmune neurological conditions remains an area of active investigation. Here, we report a case of GBS/Miller-Fisher syndrome overlap syndrome in an 80-year-old male presenting with dysarthria, dysphonia, ophthalmoplegia, areflexia, and postural instability following an upper respiratory tract infection. Cerebrospinal fluid analysis revealed the unexpected detection of herpes simplex virus type 1 DNA. Treatment with intravenous immunoglobulin therapy and acyclovir resulted in a progressive recovery of neurological symptoms. This case emphasizes the role of viral infections in differential diagnosis or as potential triggers for autoimmune neurological disorders highlighting the efficacy to addressed therapy in such complex cases.

Association of dynamic hepatic metabolism with clinical outcomes in patients with severe Guillain-Barré syndrome: A prospective cohort study from multi-centers in China

BACKGROUND AND AIMS

Little is known about the ability of serological biomarkers to monitor clinical outcomes in patients with Guillain-Barré syndrome (GBS). The objective of this study was to determine the associations of liver function, easily available and convenient biomarkers, with the clinical course and outcome of severe GBS in patients.

METHODS

A prospective data collection was conducted in a cohort of 343 GBS patients from multi-centers between September 2019 and December 2023. Serum samples were obtained at four-time points for mechanical ventilation (MV) patients and two-time points for non-MV patients. The primary endpoint was the need for MV during hospitalization, while secondary outcomes included the ability to walk independently and the mortality at 26-week follow-up.

RESULTS

(i) A total of 208 patients were eligible, of whom 50 required MV with a median (interquartile range) ventilation duration of 15 (8-27) days. (ii) Hypohepatia, as evidenced by reduced total protein (OR 0.913 [95% CI 0.862-0.967]) and albumin (0.775 [0.679-0.884]) 1 week after treatment, along with raised liver enzymes (2.732 [1.007-7.413]), was associated with the risk of MV after adjusting for confounders. (iii) After 26-week follow-up, patients with hypohepatia were less likely to regain independent walking and exhibited higher mortality in survival analysis (all log-rank p < .05). (iv) In a cross-sectional study spanning up to 4 years of follow-up, patients with prolonged MV (≥15 days) experienced a longer time to regain independent ambulation than those with shorter MV (167 [46-316] vs. 69 [24-106], p = .036). However, no relationships between liver function and prolonged MV were revealed.

INTERPRETATION

Dynamically monitoring hepatic metabolism and promptly adjusting, it can aid the improvement of GBS in patients.

Characteristics and outcomes of patients with Guillain-Barré syndrome who were admitted to the intensive care unit: a retrospective observational study

OBJECTIVE

To evaluate characteristics and outcomes in critically ill patients with Guillain-Barré syndrome (GBS).

METHODS

Consecutive adults with GBS who required intensive care unit (ICU) admission at a tertiary-care hospital between 1999 and 2020 were enrolled into this retrospective cohort study. Demographics, clinical data and patient outcomes were compared between patients who did or did not receive mechanical ventilation (MV).

RESULTS

During the study period, the number of ICU admissions gradually rose from approximately 900 to 3000 annually. Forty-three patients had GBS and were included, of whom, 27 (62.8%) received MV for a median of 13 days. The MV group stayed longer in the ICU (median, 26 versus 6 days) and in the hospital (median, 120 versus 39 days) than the non-MV group. Most patients in the MV group (22 [81.5%]) required tracheostomy. At maximum follow-up, Hughes Functional Grading scores were 0 (full recovery) in 11 patients (25.5%), 1-3 in 18 (41.8%), 4-5 in 12 (27.9%), and 6 (death) in two (4.6%, both in the MV group), with higher median Hughes score in the MV group (3 versus 0.5). Complications during ICU and hospital stay included: veinous thromboembolism in five (11.6%), gastrointestinal bleeding in three (7.0%), bacteremia in five (11.6%), bedsore in one (2.3%), and GBS-treatment side effects in four (9.4%) patients; all of these complications occurred within the MV group.

CONCLUSIONS

GBS was an uncommon reason for ICU admission. The findings highlight significant morbidity with GBS, particularly among patients who need MV.

Changes in body composition, physical fitness and quality of life on robotic gait assisted training in patients with Guillain-Barré Syndrome: a case report

PURPOSE

This case report evaluates changes in body composition, physical fitness, and quality of life in a patient with Guillain-Barre syndrome (GBS) undergoing training with an end-effector gait robotic device.

METHODS

A 35-year-old man with GBS completed interval training using a robotic gait assistant three times weekly for four weeks. The training intensity was set at 70-75% (Phase 1) and 80-85% (Phase 2) of the target heart rate, calculated using the heart rate reserve. Evaluations included body composition, physical fitness, isometric strength, gait performance, and quality of life indices.

RESULTS

Post-intervention, improvements were observed across all parameters. Body weight increased by 1.2%, while body fat percentage and visceral fat decreased by 5.4% and 3.7%, respectively. Muscle mass increased by 3.3%, and isometric strength improved at all tested sites. Gait speed increased from 0.7 to 1.8 km/h (157.1%), and the number of steps per minute increased from 33 to 77 (133.3%). The timed up-and-go (TUG) test improved by 7.1%, and exercise self-efficacy (ESE) scores increased by 29.1%.

CONCLUSION

These findings align with the principles of neuromuscular adaptation, motor learning, and neuroplasticity. Interval training with a robotic gait device may effectively restore physical function and improve quality of life in patients with GBS. However, the limitations of this single case study highlight the need for randomized controlled trials with larger cohorts and long-term effectiveness assessments.

Animal models of immune-mediated demyelinating polyneuropathies

Immune-mediated demyelinating polyneuropathies (IMDPs) are rare disorders in which dysregulated adaptive immune responses cause peripheral nerve demyelinating inflammation and axonal injury in susceptible individuals. Despite significant advances in understanding IMDP pathogenesis guided by patient data and representative mammalian models, specific therapies are lacking. Significant knowledge gaps in IMDP pathogenesis still exist, e.g. precise antigen(s) and mechanisms that initially trigger immune system activation and identification of large population disease susceptibility factors. The initial directional cues for antigen-specific effector or autoreactive leukocyte trafficking into peripheral nerves are also unknown. An overview of current animal models, with emphasis on the experimental autoimmune neuritis and spontaneous autoimmune peripheral polyneuropathy models, is provided. Insights on the initial directional cues for peripheral nerve tissue specific autoimmunity using a novel Major Histocompatibility Complex class II conditional knockout mouse strain are also discussed, suggesting an essential research tool to study cell- and time-dependent adaptive immunity in autoimmune diseases.

Diagnostic criteria and therapeutic implications of rapid-onset demyelinating polyneuropathies

Guillain-Barré syndrome (GBS) and acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) are the most common autoimmune polyneuropathies. Their aetiology is unclear. The pathomechanism includes damage mainly to the myelin sheath and, in the long-term process, secondary axonal loss. Both inflammatory polyneuropathies involve different combinations of motor, sensory and autonomic fibres in the peripheral nerves. The differential diagnosis should be based on clinical and neurophysiological features, and laboratory tests. Numerous studies aim to demonstrate the most common errors in the diagnosis of Guillain-Barré syndrome and acute-onset CIDP. Misdiagnosis can result in the wrong treatment. We still do not have reliable markers to help diagnose the disease or to monitor the effectiveness of the therapy.

Guillain-Barré Syndrome in Africa: Understanding, Addressing, and Empowering

Introduction

Guillain-Barré Syndrome (GBS) is a spectrum of peripheral neuropathies characterized by rapid symmetrical limb weakness and sensory symptoms. GBS can be life-threatening and requires intensive care, particularly for patients with imminent respiratory failure. In Africa, limited research and high therapy costs pose challenges. This literature review aims to comprehensively address GBS in Africa to improve understanding and outcomes.

Aim

This literature review aims to provide an extensive overview of GBS in Africa, encompassing its clinical presentation, impact, management approaches, and challenges faced. It also highlights the need for increased research and awareness to enhance patient care and outcomes.

Methods

A comprehensive review of existing literature on GBS in Africa was conducted, focusing on clinical presentation, diagnosis, management, and its impact on patients and communities. Data sources included medical databases, research articles, and reports. Data was scoured from databases such as PubMed, Medline and Embase. A total of four hundred and fifty-five articles and case studies were screened, with broader topic margins into GBS and different triggers, demographics, statistics, and variations in treatments across the world. These articles were further screened to match our inclusion criteria which focused on articles published after 2000 and which gave clearer insights into the presentations and situation of GBS in the African continent.

Results

GBS in Africa is characterized by a range of clinical presentations, with limited diagnostic resources and healthcare infrastructure. Patients often face long intervals between symptom onset and hospitalization, impacting outcomes. The syndrome's impact extends beyond physical symptoms, affecting patients' quality of life, employment, and community roles. Management involves immunotherapy, physiotherapy, and psychosocial support, but high therapy costs and incomplete recovery pose challenges. Research in Africa has grown in recent years but remains limited compared to other regions. Efforts are needed to expand research capacity, introduce early screening programs, and improve healthcare infrastructure.

Conclusion

GBS presents a significant healthcare challenge in Africa, with the potential for severe clinical outcomes. This literature review underscores the importance of enhancing research, awareness, and healthcare infrastructure. African-led research initiatives offer hope for improved patient outcomes and healthcare system strengthening. By advocating for increased government support and resources, Africa can address the pressing needs of GBS patients and foster a brighter and healthier future for affected individuals on the continent.