Assessment of Guillain-Barré syndrome mortality and morbidity in the United States: implications for acute flaccid paralysis surveillance

A 'Decrescendo' in a Woman With Ascending Paralysis: A Diagnostic Challenge

Guillain-Barre Syndrome (GBS) is an autoimmune condition that causes muscular weakness and can be potentially life-threatening if not identified early. GBS is diagnosed definitively by cerebrospinal fluid (CSF) analysis and electromyographic (EMG) studies. Identifying illnesses that may have triggered GBS is crucial, as they could affect the course of the disease. Our patient was a 27-year-old woman who developed lower extremity weakness a few days after being treated for a dental abscess. Laboratory and imaging studies ruled out central nervous system (CNS) lesions, myelopathies, and metabolic causes. Diagnosis was difficult due to inconclusive initial investigations, refusal of lumbar puncture, and delayed availability of EMG studies. Additionally, there were no identifiable triggers to support GBS as a diagnosis. During the hospital course, the patient developed tachycardia with new electrocardiogram (EKG) changes. A transthoracic echocardiogram (TTE) showed suspicious vegetation, and a transesophageal echocardiogram (TEE) confirmed severe mitral regurgitation. The new valvular lesions and autonomic dysfunction with worsening lower extremity weakness increased our suspicion of GBS. Intravenous immunoglobulin (IVIG) was administered empirically, but she developed bulbar symptoms, prompting admission to the intensive care unit (ICU). A lumbar puncture performed at this time was negative for albumino-cytological dissociation and CNS infections.  Signs of sepsis with valvular lesions raised concerns for infective endocarditis (IE). Due to recent treatment with antibiotics for dental abscess, a negative blood culture was a confounding factor in Duke's criteria, delaying the diagnosis of IE. Infectious disease experts suggested empirical treatment for suspected blood culture-negative infective endocarditis (BCNE) and valvular abscess. She was transferred to a cardiothoracic care facility for valvular surgery evaluation. EMG studies identified the patient's condition as the acute motor sensory axonal neuropathy (AMSAN) variant of GBS. The patient's antibodies tested positive for Campylobacter jejuni (C. Jejuni) immunoglobulin G (IgG). Since this indicates a past infection, it is uncertain whether C. Jejuni triggered the patient's GBS. However, new valvular vegetation and acute-onset lower extremity weakness make us hypothesize that BCNE may have triggered GBS.

Analysis of Post-COVID-19 Guillain-Barré Syndrome over a Period of One Year in the University Hospital of Split (Croatia)

The virus SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) is capable of attacking the nervous system in several ways and leading to neurological diseases such as GBS (Guillain-Barré syndrome) through the resulting neurotropism and immune response. The aim of this study is to show the relationship between Coronavirus disease (COVID-19) and GBS and to better understand the clinical symptoms to prevent poor outcomes. Data from 15 patients were extracted from the Department of Neurology, University Hospital of Split, Croatia, for the year 2021. The age of the patients ranged from 26 to 89 years, of whom 27% were women. Sixty seven percent of all GBS patients recovered from COVID-19 infection, whereas post-vaccinal polyradiculoneuritis was detected in 6%. Forty four percent of the patients who developed GBS had a severe form of COVID-19 infection. Forty percent of patients were treated with intravenous immunoglobulins (IVIG), followed by therapeutic plasma exchange (PLEX) in 27%. After the therapy, improvement was observed in 13 patients, while two patients died. The results suggest that SARS-CoV-2 triggers GBS because it follows a similar pattern of infection as the other viral and bacterial agents that contribute to the onset of GBS. There is no evidence that prior infection with COVID-19 worsens the clinical presentation of GBS.

Risk of Guillain-Barré Syndrome Among Older Adults Receiving Influenza Vaccine in Taiwan

IMPORTANCE

Although influenza vaccination has been associated with Guillain-Barré syndrome (GBS), the findings among studies of older adult populations are inconsistent.

OBJECTIVE

To determine the risk of GBS after influenza vaccination among older adults.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study incorporated a self-controlled case series design. Days 1 to 7, days 1 to 14, and days 1 to 42 after influenza vaccination were identified as risk intervals; days 8 to 180, days 15 to 180, and days 43 to 180 comprised the corresponding control interval. Population-based data were obtained from Taiwan's National Health Insurance research database between January 1, 2003, and December 31, 2017. Data were analyzed from November 1, 2021, through February 28, 2022. Adults 65 years or older who developed GBS within 180 days after influenza vaccination were enrolled.

EXPOSURE

Government-funded seasonal influenza vaccination.

MAIN OUTCOMES AND MEASURES

Onset of GBS during risk intervals after influenza vaccination compared with control intervals using Poisson regression to calculate incidence rate ratio (IRR).

RESULTS

Of 13 482 122 adults aged 65 years or older who received an influenza vaccination, 374 were hospitalized for GBS. The mean (SD) age of the study population was 75.0 (6.1) years; 215 (57.5%) were men and 159 (42.5%) were women. In terms of comorbidities, 33 adults (8.8%) had cancer and 4 (1.1%) had autoimmune diseases. The IRRs for GBS during days 1 to 7, days 1 to 14, and days 1 to 42 were 0.95 (95% CI, 0.55-1.61; P = .84), 0.87 (95% CI, 0.58-1.29; P = .48), and 0.92 (95% CI, 0.72-1.17; P = .49), respectively. No results showed statistical significance. Similarly, no significant differences in IRRs were noted for the overall risk interval (ie, days 1-42) in subgroup analyses pertaining to different age groups (65-74 years [0.93 (95% CI, 0.66-1.31)], 75-84 years [0.85 (95% CI, 0.58-1.26)], and ≥85 years [1.10 (95% CI, 0.57-2.11)]), sex (men, 0.97 [95% CI, 0.71-1.33; P = .87]; women, 0.85 [95% CI, 0.58-1.23; P = .39]), Charlson Comorbidity Index (1.03 [95% CI, 0.77-1.38; P = .84]), or comorbidities (cancer, 0.68 [95% CI, 0.28-1.64; P = .39]; autoimmune disease, 1.10 [95% CI, 0.11-10.53; P = .94]).

CONCLUSIONS AND RELEVANCE

These findings suggest that influenza vaccination did not increase the risk of GBS among adults aged 65 years or older in Taiwan regardless of postvaccination period or underlying characteristics.

Guillain-Barré syndrome and antecedent cytomegalovirus infection, USA 2009-2015

OBJECTIVE

To describe incidence and clinical characteristics of cases of Guillain-Barré syndrome (GBS) in the USA during 2009-2015, and characteristics of GBS cases with antecedent cytomegalovirus (CMV) infection among persons with employer-sponsored insurance.

METHODS

We analyzed medical claims from IBM Watson MarketScan® databases. GBS patients were defined as enrollees with an inpatient claim with GBS as the principal diagnosis code, based on ICD-9 or ICD-10, and ≥ 1 claim for lumbar puncture or EMG/nerve conduction study. We assessed intensive care unit (ICU) hospitalization, intubation, dysautonomia, and death. We also assessed selected infectious illness within 60 days prior to the first GBS-coded inpatient claim.

RESULTS

We identified 3486 GBS patients; annual incidence was 1.0-1.2/100,000 persons during 2009-2015. GBS incidence was higher in males (1.2/100,000) than in females (0.9/100,000) (p = 0.006) and increased with age, from 0.4/100,000 in persons 0-17 years old to 2.1/100,000 in persons ≥ 65 years old (p < 0.001). Half of GBS patients were hospitalized in the ICU, 8% were intubated, 2% developed dysautonomia, and 1% died. Half had a claim for antecedent illness, but only 125 (3.5%) had a claim for specific infectious pathogens. The mean age among 18 GBS patients with antecedent CMV infection was 39 years versus 47 years among those without antecedent  CMV infection (p = 0.038).

CONCLUSIONS

Incidence of GBS using a large national claims database was comparable to that reported in the literature, but cases appeared to be less severe. Half of GBS patients reported prior infectious illness, but only a minority had a specific pathogen identified.

The Epidemiology of Neuromuscular Diseases

Neuromuscular disorders as a group are linked by anatomy with significant differences in pathogenetic mechanisms, clinical expression, and time course of disease. Each neuromuscular disease is relatively uncommon, yet causes a significant burden of disease socioeconomically. Epidemiologic studies in different global regions have demonstrated certain neuromuscular diseases have increased incidence and prevalence rates over time. Understanding differences in global epidemiologic trends will aid clinical research and policies focused on prevention of disease. There is a critical need to understand the global impact of neuromuscular diseases using metrics currently established for communicable and noncommunicable diseases.

Uncommon Disorders Masquerading as Acute Flaccid Paralysis in Children

The syndrome of acute flaccid paralysis (AFP) is a common medical emergency in children. In the era of poliomyelitis eradication, the common causes of AFP include Guillain-Barré syndrome (GBS), transverse myelitis and traumatic neuritis. However, many common diseases can uncommonly present as AFP and some uncommon diseases may also masquerade like it. Uncommon causes of AFP seen at a tertiary care pediatric hospital are discussed along with relevant points in diagnosis and management. Also, common pitfalls in diagnosis of pediatric AFP and an approach to investigations are discussed.

Pandemic influenza A vaccination and incidence of Guillain-Barré syndrome in Korea

BACKGROUND

Many studies have investigated the association between Guillain-Barré syndrome (GBS) and vaccinations during the influenza A H1N1 pandemic of 2009 (pH1N1). Based on a nationally representative sample, we estimated the incidence of GBS during the pandemic period in Korea.

MATERIALS AND METHODS

All medical records of GBS cases were reviewed in 28 randomly selected hospitals during 2008-2010, and the number of GBS cases at the national level was extrapolated using emergency care utilization data. The GBS rate per 100,000 person-years was estimated in the reference and pandemic periods.

RESULTS

The incidence of GBS was 0.63 (95% CI: 0.37-0.89) per 100,000 person-years in the reference period and 0.87 (0.49-1.26) in the pandemic period. During the vaccination season, the pandemic period GBS incidence rate was not significantly higher than the reference period incidence rate (rate ratio: 1.52; 0.99-2.32), but difference was observed among persons aged 20-34 years. Rate of GBS increased after pH1N1 vaccination compared to the reference period (1.46, 1.26-1.68).

DISCUSSION

The incidence of GBS increased slightly but not significantly during the pandemic period, although pH1N1 vaccination increased the GBS rate. Therefore, mass influenza vaccination programs should not be precluded on the basis of GBS.

Pandemic A/H1N1 2009 influenza vaccination, preceding infections and clinical findings in UK children with Guillain-Barré syndrome

OBJECTIVE

To record clinical findings in all new cases of Guillain-Barré syndrome (GBS) or Fisher syndrome (FS) in UK children in the 2 years following September 2009 and determine the proportion temporally associated with recent infections, pandemic H1N1 (2009) strain influenza vaccination or seasonal influenza vaccination.

DESIGN

A prospective UK-wide epidemiological study using the British Paediatric Surveillance Unit system.

PATIENTS

Children aged 16 years or less meeting the Brighton Collaboration criteria for GBS or FS.

RESULTS

112 children with GBS (66 boys and 46 girls) and 3 boys with FS were identified in 2 years. All but one recovered sufficiently to go home. The annual UK incidence rate of GBS in patients less than 15 years old was 0.45/100 000, similar to other countries. There was evidence of infection in the 3 months preceding onset in 92/112 GBS and 3/3 FS cases. Of those living in England, 7 cases received pandemic A/H1N1 2009 influenza vaccination before GBS symptom onset (3/7 were within 6 months including 1 within 3 months); 2 children received 2010/2011 seasonal influenza vaccination within 6 months of GBS onset. The numbers vaccinated were not significantly greater than expected by chance.

CONCLUSIONS

The outcome for childhood GBS and FS after 6 months was better than reported in adults. Most UK GBS and FS cases had infections in the preceding 3 months. When considering the children living in England, there was no significantly increased risk of GBS after pandemic A/H1N1 2009 influenza vaccination or 2010/2011 seasonal influenza vaccination.

Paralytic syndromes in children: epidemiology and relationship to vaccination

Acute flaccid paralysis is a standard outcome for detection of poliomyelitis globally and an ongoing potential vaccine-associated adverse event concern for polio, influenza, and meningococcal vaccines. No systematic population-based data on the epidemiologic and clinical features of this condition, or its potential association with immunization, have been reported from the United States. The present retrospective cohort study of acute flaccid paralysis in the Southern and Northern California Kaiser Permanente Health Care Plans was conducted using computerized diagnosis data and medical record review of potential cases among children aged 1 month to <15 years and diagnosed from January 1, 1992 through December 31, 1998. In all, 3297 potential cases were identified; of these, 2682 cases (81%) did not meet the case definition, and of the remaining 615 cases, 245 (7% of the total) were included. The incidence of disease was 1.4 per 100,000 children/year (95% confidence interval = 1.2-1.6); predicting approximately 844 children/year in the United States. Disease incidence did not vary with season or sex, varied inversely with age, and declined 28% during the study period. No cases of vaccine-associated acute flaccid paralysis were identified. In nonendemic countries, ongoing acute flaccid paralysis surveillance is often conducted, because of the risk of poliovirus importation, but this practice may be difficult to justify, given low disease incidence and breadth of clinical presentation.

Epidemiology of Guillain-Barré syndrome in the province of Quebec

BACKGROUND

In the province of Quebec, a population-based study of Guillain-Barré syndrome (GBS) was conducted at the time of a mass immunization campaign against meningococcal disease, in 2001.

METHODS

The study population included residents aged 2 months to 20 years observed from November 1st, 2000 to December 31, 2002, representing 4,075,465 person-years of observation. GBS cases were identified in the provincial hospital database Med-Echo and medical records were reviewed.

RESULTS

Thirty-three incident GBS cases were identified, including 27 cases of acute inflammatory demyelinating polyradiculopathy. The overall GBS incidence rate was 0.8/100,000 person-years, higher in persons aged 1 to 4 years (2.1/100,000) than in those 5 years or more (0.6/100,000). There was a female preponderance and no significant seasonal variation. All patients survived.

CONCLUSION

Results could be used to interpret reports of adverse events associated with the introduction of new vaccines in this age-group in Canada.

Pharmacoeconomics of therapy for Guillain-Barré syndrome: plasma exchange and intravenous immunoglobulin

Guillain-Barré syndrome (GBS) is an acute neuropathy and a clinical syndrome that includes a number of pathological and electrophysiological subtypes. Intravenous immunoglobulin (IVIG) and plasma exchange (PE) are both equally efficacious for the treatment of GBS; however, the cost of IVIG may be lower for both the patient and the healthcare system. To compare the pharmacoeconomics of PE and IVIG in GBS, a retrospective study was done from 1999 to 2004, which included a total of 24 patients with GBS who were admitted to Taipei Veterans General Hospital. This showed that except for the costs of the drugs used in IVIG, treatment of GBS with IVIG was more cost-effective (p=0.057) than that with PE in total length of hospitalization and the cost of procedures and hospitalization. The study also showed that the total costs were higher for patients on ventilators than those not requiring ventilators (p=0.008, t-test) and the length of hospitalization showed a very strong linear relationship to total costs (Pearson correlation coefficient=0.907). The regression analysis showed that each additional day of hospitalization increased the hospitalization costs by an average of 5599 New Taiwan Dollars (NT) (US$1.00=NT$33.50 in 2005).

Can a Minimum Rate of Investigation of Measleslike Illnesses Serve as a Standard for Evaluating Measles Surveillance?

To determine whether measles case finding is sensitive, we developed a standard by which to evaluate measles surveillance. We compiled data on the incidence of measleslike illnesses (MLIs) from multiple, diverse sources and used the distribution of these values to determine the minimum level of measles case-finding activity that could be expected in a given region. Among surveillance programs in the United States, other countries in the Americas, and other World Health Organization regions, the median annual rates for rash investigations that were ruled out for measles were 4.3, 4.1, and 1.8/100000 population, respectively. The annual rates of measles IgM testing in the United States in public laboratories and commercial laboratories were 1.6 and 9.2/100000 population, respectively. In total, we collected data on annual MLI incidence from >80 sources. Values ranged from 0.1 to 22.6 cases of MLI per 100000 population, and 90% of values were >or=1.0/100000 population. On the basis of these findings, we propose that programs attempting measles elimination consider evaluating surveillance by comparing the annual rate of suspected measles investigations against a minimum standard of 1/100000 population.

Epidemiologic features of Guillain-Barré syndrome in São Paulo, Brazil

INTRODUCTION

There are few epidemiologic studies concerning Guillain-Barré syndrome (GBS). Due to difficulties with definition and lack of a standard diagnostic test of reference, GBS is not easy to study epidemiologically. We evaluate some epidemiological features of GBS in a sample of cases treated at a tertiary hospital in São Paulo, Brazil.

METHOD

We retrospectively reviewed all cases of GBS with hospitalization in Santa Marcelina hospital, over the period of January 1995 through December 2002.

RESULTS

Ninety-five cases were included in this study. Fifty-five were men and forty women, with a proportion of 1.4 men to 1 woman. The age ranged from 1 to 83 years with a mean age at onset of 34 years. GBS was less frequently observed below 15 years (18.9%) and above 60 years (16.9%). The highest frequency was observed in patients aged 15 to 60 years old (66.2%). The annual incidence rate was 0.6 cases/100,000 people. There was a highest frequency of cases during the months of September through March (62.1%).

CONCLUSION

Our data differs from that of other epidemiological studies in that we did not observe a bimodal distribution in age and found a seasonal pattern in hotter months.

Five-year surveillance of acute flaccid paralysis in Malaysia

OBJECTIVE

The nation-wide surveillance for acute flaccid paralysis (AFP) was implemented in Malaysia in 1995 and further intensified in 1996 as part of the World Health Organization's (WHO) certification process for polio eradication in the Western Pacific Region. Clinical data on AFP cases during a 5-year surveillance period from 1997 to 2001 were compiled and analysed.

RESULTS

Based on 517 cases of AFP reported during this 5-year period, the overall rate of AFP was 1.2 per 100 000 children below 15 years old. The major clinical diagnosis associated with AFP were Guillain-Barre syndrome (30.2%), central nervous system infection (16.2%), transverse myelitis (10.6%) non-polio enterovirus infection (6.2%), and hypokalaemic paralysis (5.2%). This unusual pattern with an excess of CNS infection and non-polio enterovirus infection was attributed to the outbreak of enterovirus 71 infection nation-wide in 1997. According to the WHO virological classification, there was no case of poliomyelitis due to wild poliovirus. Three cases were 'polio compatible', there were no cases of vaccine-associated paralytic polio (VAPP), while 62 cases (12.0%) were merely classified as 'non-polio AFP'.

CONCLUSION

Overall, these data suggest the absence of circulation of wild poliovirus in Malaysia from 1997 to 2001. The pattern of AFP in this study is different from other published reports.

Peripheral Neuropathy

This chapter focuses on peripheral neuropathy, which is the third or fourth most common neurologic disorder, even among the elderly. It begins with a description of the classification system for peripheral neuropathies. Because the underlying etiology or precipitating events of peripheral neuropathy are identifiable for the majority of affected individuals, epidemiologic research has largely focused on descriptive studies of disease frequency or on identifying the factors that modify the influence of the already existing risk factors. Three of the most common neuropathies are covered in detail: diabetic neuropathy, carpal tunnel syndrome, and Guillain–Barré syndrome. Each of these conditions is discussed in terms of distribution and risk factors, and is concluded with a discussion of future research directions to address unanswered questions. The chapter emphasizes methodologic approaches that that could be employed to improve the rigor of studies of these conditions.

Guideline for Neuromuscular Rehabilitation in Guillain-Barré Syndrome

Introduction. Originally described by Landry in 1859 and Guillain, Barré and Strohl in 1916, Guillain-Barré Syndrome (GBS) is the most common cause of acute neuromuscular paralysis selflimited in developed countries. The annual incidence of GBS is 1.5 per 100,000. Although it had a favorable prognosis (“maladie bénigne et spontanément curable”) it’s mortality rate is about 5% and 10% of patients remaining severely disabled one year after neurological onset. Specialist teams, intensive care and rehabilitation are essential for patient management and should be provided in appropriate hospital units. Objective. To guide the health professionals about the utilization of the physical and respiratory techniques in patients with GBS, as well as it’s indication. Method. Update of articles about GBS and Rehabilitation, on the last years of the data bases Bireme, ScienceDirect, PubMed and SciELO. Conclusion. There is currently no consensus on the management of these patients in the acute, sub-acute and chronic settings. Many of them are being discharged without access to rehabilitation services. Our results suggest that the rehabilitation makes a measurable and significant difference and should be available to all patients with GBS.

Pathogenesis of Guillain-Barré syndrome

Recent neurophysiological and pathological studies have led to a reclassification of the diseases that underlie Guillain-Barré syndrome (GBS) into acute inflammatory demyelinating polyradiculoneuropathy (AIDP), acute motor and sensory axonal neuropathy (AMSAN) and acute motor axonal neuropathy (AMAN). The Fisher syndrome of ophthalmoplegia, ataxia and areflexia is the most striking of several related conditions. Significant antecedent events include Campylobacter jejuni (4-66%), cytomegalovirus (5-15%), Epstein-Barr virus (2-10%), and Mycoplasma pneumoniae (1-5%) infections. These infections are not uniquely associated with any clinical subtype but severe axonal degeneration is more common following C. jejuni and severe sensory impairment following cytomegalovirus. Strong evidence supports an important role for antibodies to gangliosides in pathogenesis. In particular antibodies to ganglioside GM1 are present in 14-50% of patients with GBS, and are more common in cases with severe axonal degeneration associated with any subtype. Antibodies to ganglioside GQ1b are very closely associated with Fisher syndrome, its formes frustes and related syndromes. Ganglioside-like epitopes exist in the bacterial wall of C. jejuni. Infection by this and other organisms triggers an antibody response in patients with GBS but not in those with uncomplicated enteritis. The development of GBS is likely to be a consequence of special properties of the infecting organism, since some strains such as Penner 0:19 and 0:41 are particularly associated with GBS but not with enteritis. It is also likely to be a consequence of the immunogenetic background of the patient since few patients develop GBS after infection even with one of these strains. Attempts to match the subtypes of GBS to the fine specificity of anti-ganglioside antibodies and to functional effects in experimental models continue but have not yet fully explained the pathogenesis. T cells are also involved in the pathogenesis of most or perhaps all forms of GBS. T cell responses to any of three myelin proteins, P2, PO and PMP22, are sufficient to induce experimental autoimmune neuritis. Activated T cells are present in the circulation in the acute stage, up-regulate matrix metalloproteinases, cross the blood-nerve barrier and encounter their cognate antigens. Identification of the specificity of these T cell responses is still at a preliminary stage. The invasion of intact myelin sheaths by activated macrophages is difficult to explain according to a purely T cell mediated mechanism. The different patterns of GBS are probably due to the diverse interplay between antibodies and T cells of differing specificities.

Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is viewed as a reactive, self-limited, autoimmune disease triggered by a preceding bacterial or viral infection. Campylobacter jejuni, a major cause of bacterial gastroenteritis worldwide, is the most frequent antecedent pathogen. It is likely that immune responses directed towards the infecting organisms are involved in the pathogenesis of GBS by cross-reaction with neural tissues. The infecting organism induces humoral and cellular immune responses that, because of the sharing of homologous epitopes (molecular mimicry), cross-react with ganglioside surface components of peripheral nerves. Immune reactions against target epitopes in Schwann-cell surface membrane or myelin result in acute inflammatory demyelinating neuropathy (85% of cases); reactions against epitopes contained in the axonal membrane cause the acute axonal forms of GBS (15% of cases). Care for such patients may be challenging, yet the prognosis overall is favourable. Optimal supportive care and anticipation and prevention of complications are the mainstay of therapy. Admission to the intensive-care unit is necessary in 33% of patients who require intubation and assisted ventilation. Immunomodulation with infusions of IgG or plasma exchange treatments foreshorten the disease course.