Epidemiology of the Guillain-Barré syndrome

Effect of the Task Approach, Airway Clearance, Kinesthetic Exercise (TASKS) Paediatric Rehabilitation Protocol on Miller-Fisher Syndrome Variant of Guillain-Barré Syndrome: A Case Report

Miller-Fisher syndrome (MFS) is a rare variant of Guillain-Barré syndrome (GBS) with varying incidence rates geographically. MFS is primarily diagnosed based on clinical features, such as ataxia and areflexia, although other neurological symptoms may also present. A case of MFS has been presented, characterized by complaints of ataxia, areflexia, bilateral foot and hand pain and difficulty in swallowing. In this regard, a paediatric rehabilitation approach has been adopted, utilizing outcome measures, such as the Erasmus Guillain-Barre Syndrome Respiratory Insufficiency Score-Kids, WeeFIM and paediatric balance scale, in addition to clinical evaluation. It is worth noting that the presented case demonstrates the importance of accurately diagnosing and treating this rare neurological condition MFS. Through the implementation of appropriate rehabilitation strategies, it is possible to enhance patients' quality of life.

The characteristics of Guillain-Barre syndrome in children in pre-COVID-19 and during the COVID-19 pandemic: A cross-sectional study

Background and Aims

In the pathophysiology of Guillain-Barre syndrome (GBS), inflammation and immunity are believed to play a key role. The neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), and platelet-lymphocyte ratio (PLR) have been recently identified as potential markers of inflammation or immunity. This study aimed to investigate whether NLR, MLR, and PLR are associated with GBS characteristics in children. We also assessed the impact of the COVID-19 pandemic on the characteristics of GBS in Iran.

Methods

In this retrospective cross-sectional study, we reviewed the records of all 150 children diagnosed with GBS in the Children's Medical Center hospital affiliated with Tehran University of Medical Sciences (TUMS) from March 2017 until March 2022. The TUMS research ethics committee approved the study (Ethics code: IR.TUMS.CHMC.REC.1399.125). Patients' data including gender, age, clinical symptoms, laboratory findings, and electrodiagnostic study results were collected and analyzed.

Results

This study involved 150 children, comprising 93 boys and 57 girls, with an average age of 7.53 ± 3.75 years. The analysis demonstrated that the number of hospitalization days increased with an increase in NLR (p = 0.025). Moreover, patients with abnormal electrodiagnostic study patterns had a higher risk of intensive care unit (ICU) admission (p: 0.027), although according to binary logistic regression, respiratory failure at admission time was the only significant factor increasing the risk of ICU admission (p = 0.035). The study also found that the pandemic has resulted in a shift from acute inflammatory demyelinating polyneuropathy to acute motor axonal neuropathy as the most common EMG-NCV pattern in our patients (p < 0.001).

Conclusion

We found that higher NLR was associated with a longer hospitalization duration and could potentially distinguish between severe and mild cases of GBS. We have also shown that the COVID-19 pandemic has changed our patients' most frequent electromyography and nerve conduction velocity (EMG-NCV) patterns.

Characteristics of Patients Diagnosed With Guillain-Barré Syndrome at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, From 2000 to 2018

BACKGROUND

Guillain-Barré syndrome (GBS) is the leading cause of non-polio acute flaccid paralysis worldwide, emphasizing the importance of epidemiological studies on this condition. Therefore, well-designed epidemiological studies in different populations can provide a better understanding of the characteristics of patients with GBS and the nature of the disease. To our knowledge, no previous study has attempted to describe the characteristics of patients with GBS in Kingdom of Saudi Arabia (KSA) based on disease subtypes and clinical features in both adult and pediatric patients. This study aimed to assess the frequencies of GBS subtypes and their relationships with patient characteristics and clinical data in a tertiary hospital in Jeddah, KSA.

METHODS

This was a retrospective review of patients diagnosed with GBS between January 2000 and January 2018 at King Abdulaziz University Hospital (KAUH), a tertiary center in Jeddah, KSA.

RESULTS

In total, 47 patients with GBS (median age: seven years for pediatric and 36 years for adult patients) were included in the current study. There were six male and three female pediatric patients and 19 male and 19 female adult patients. Among patients with GBS who were classified into a specific electrophysiological subtype (n = 28), 13 (46.2%) had acute inflammatory demyelinating polyneuropathy (AIDP), 11 (39%) had an axonal subtype, and four (14%) had Miller Fisher syndrome (MFS). Patients required prolonged hospitalization of approximately 20 ± 22 days (2.83 ± 3.11 weeks). Patients with MFS were more likely to have higher cytoalbuminologic dissociation than those with other subtypes.

CONCLUSION

AIDP was the most frequent type of GBS, followed by the axonal type. Patients required prolonged hospitalization of approximately 20 ± 22 days (2.83 ± 3.11 weeks). Patients with MFS were more likely to have higher cytoalbuminologic dissociation than those with other subtypes. GBS type did not show a relationship with ICU admission or mechanical ventilation use. There was no association between specific therapies and different GBS subtypes and no significant difference in outcomes between different patterns of clinical presentation. Intravenous immunoglobulin (IVIg) and plasma exchange (PE) treatments both had the same efficacy in relation to outcomes for patients with GBS.

Neuropathic Tremor in Guillain-Barré Syndrome

Background

Neuropathic Tremor (NT) is a postural/kinetic tremor of the upper extremity, often encountered in patients with chronic neuropathies such as paraprotein-associated and hereditary neuropathies.

Objectives

To describe the clinical and electrophysiological features of NT in a previously underrecognized setting- during recovery from Guillain-Barré Syndrome (GBS).

Methods

Patients with a documented diagnosis of GBS in the past, presenting with tremor were identified from review of clinical records. Participants underwent structured, videotaped neurological examination, and electrophysiological analysis using tri-axial accelerometry-surface electromyography. Tremor severity was assessed using the Fahn-Tolosa-Marin Tremor Rating Scale.

Results

We describe the clinical and electrophysiological features of 5 patients with GBS associated NT. Our cohort had a fine, fast, and slightly jerky postural tremor of frequency ranging from 8 to 10 Hz. Dystonic posturing and overflow movements were noted in 4/5 patients. Tremor appeared 3 months-5 years after the onset of GBS, when patients had regained near normal muscle strength and deep tendon jerks were well elicitable. Electrophysiological analysis of tremor strongly suggested the presence of a central oscillator in all patients.

Conclusion

NT is not limited to chronic inflammatory or hereditary neuropathies and may occur in the recovery phase of GBS. The tremor is characterized by a high frequency, jerky postural tremor with dystonic posturing. Electrophysiological evaluation suggests the presence of a central oscillator, hypothetically the cerebellum driven by impaired sensorimotor feedback.

Post COVID-19 vaccination Guillain-Barre syndrome: three cases

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy. In two-thirds of patients, it is preceded by an upper respiratory or gastrointestinal tract infection. Temporally associated cases of GBS following COVID-19 vaccination have been described with different COVID-19 vaccines. In this study, we report three cases of GBS patients following COVID-19 vaccine. Two of the studied patients received the Sinopharm vaccine and one patient received the AstraZeneca vaccine. All patients were diagnosed with acute motor axonal neuropathy (AMAN) type of GBS, on nerve conduction studies. All three patients responded well to treatment with intravenous immunoglobulin (IVIg). The association between COVID-19 vaccination and GBS is not well understood and more studies are needed to establish whether it is merely an association or a causal relationship.

COVID-19 Vaccination a Cause of Guillain-Barré Syndrome? A Case Series

Guillain-Barré syndrome (GBS) is a rare autoimmune neuropathic disorder of peripheral nerves usually following an infection or on rarer occasions following vaccinations, but the exact underlying pathophysiology is still unclear. The most common etiology of GBS is a bacterial infection caused by Campylobacter jejuni. Viral infections like Zika virus, Epstein-Barr virus, and Cytomegalovirus also add to the list of GBS etiology. COVID-19 (SARS-CoV-2) has also been reported to cause GBS. Vaccines like the rabies vaccine, influenza vaccine, and poliovirus vaccine account for a very small fraction of Guillain-Barré syndrome. GBS as an adverse effect of COVID-19 vaccination was not reported by the Vaccine Adverse Event Reporting System (VAERS), but an update was later released in the course of the pandemic from FDA news, reporting several patients developing GBS after receiving the COVID-19 vaccine. In this case series, we discuss five cases that developed the GBS post-COVID-19 AstraZeneca vaccine, along with its pathophysiology, management, and outcome.

Atypical Guillain-Barré Syndrome Presenting After COVID-19 Infection

Guillain-Barré syndrome (GBS) is an acute autoimmune disease affecting the peripheral nervous system presenting as a symmetric, ascending polyneuropathy. The syndrome arises after a stimulus, such as infection or vaccination, and provokes an autoimmune response in the body. Common symptoms include rapidly progressive weakness in the extremities and generalized hyporeflexia or areflexia. However, GBS may have various presentations, which can make for a challenging diagnosis. We present a case of a 46-year-old female with asymmetric ascending weakness, paresthesias, and acute onset urinary retention occurring after Coronavirus Disease 2019 (COVID-19) infection. Of note, this patient did not present with albuminocytologic dissociation in cerebrospinal fluid (CSF) studies. The complex presentation of her symptoms prompted a diagnosis of atypical GBS. Her diagnosis was achieved through a series of diagnostic tests ruling out other etiologies, such as meningitis and spinal cord compression syndromes. 

Frequency of exposure to arboviruses and characterization of Guillain Barré syndrome in a clinical cohort of patients treated at a tertiary referral center in Brasília, Federal District

Background:

Guillian Barré syndrome (GBS) is an acute autoimmune polyradiculoneuropathy often associated with previous exposure to infectious agents.

Methods:

A clinical cohort of 41 patients with GBS admitted to the Base Hospital Institute of the Federal District between May 2017 and April 2019 was followed up for 1 year. Serological tests for arbovirus detection and amplification of nucleic acids using polymerase chain reaction for zika virus (ZIKV), dengue virus (DENV), and chikungunya virus (CHIKV) were performed.

Results:

The cohort consisted of 61% men with a median age of 40 years, and 83% had GBS-triggering events. A total of 54% had Grade 4 disability, 17% had Grade 3, 12% had Grade 2, 10% had Grade 5, and 7% had Grade 1. The classic form occurred in 83% of patients. Nerve conduction evaluations revealed acute demyelinating inflammatory polyneuropathy (51%), acute motor axonal neuropathy (17%), acute sensory-motor neuropathy (15%), and indeterminate forms (17%). Four patients were seropositive for DENV. There was no laboratory detection of ZIKV or CHIKV infection. Ninety percent of patients received human immunoglobulin. Intensive care unit admission occurred in 17.1% of the patients, and mechanical ventilation was used in 14.6%. One patient died of Bickerstaff’s encephalitis. Most patients showed an improvement in disability at 10 weeks of follow-up.

Conclusions:

GBS in the Federal District showed a variable clinical spectrum, and it was possible to detect recent exposure to DENV.

Epidemiology of Guillain-Barré Syndrome in Iranian Children Aged 0-15 Years (2008-2013)

Objective

Guillain-Barré Syndrome (GBS) is an acute inflammatory polyneuropathy characterized by a rapid progressive symmetric weakness. The GBS is the most common cause of acute flaccid paralysis (AFP) in most parts of the world. This study was carried out to investigate the epidemiological features of GBS in Iranian children.

Materials & Methods

The data were extracted using the AFP surveillance system that is a national screening program to detect all cases of AFP aged 0-15 years around the country. National Population Statistics data and AFP demographic data during 2008-2013 intervals were obtained from the relevant authorities in the Ministry of Health in Iran. The GBS cases were then extracted from the aforementioned database. The Chi-square test and Fisher’s exact test were used for statistical analysis.

Results

A total of 1884 cases of GBS were identified in the study period, and the average annual incidence rate was 1.72 per 100,000 individuals. The highest incidence rate was within the range of 0-5 years. There was no statistically significant relationship between the incidence of GBS and the season in the whole country.

Conclusion

High costs of GBS treatment, morbidity and occasional mortality, and number of new cases, which is estimated to be approximately 300 individuals per year, need the particular attention of the health system.

Guillain-Barre Syndrome and COVID-19 Vaccine: A Report of Nine Patients

Introduction:

Guillain-Barre Syndrome (GBS) is an autoimmune acute inflammatory demyelinating polyneuropathy usually elicited by an upper respiratory tract infection. Several studies reported GBS associated with Coronavirus Disease 2019 (COVID-19) infection. In this study, we described nine GBS patients following the COVID-19 vaccine.

Methods:

In this study, nine patients were introduced from six referral centers for neuromuscular disorders in Iran between April 8 and June 20, 2021. Four patients received the Sputnik V, three patients received the Sinopharm, and two cases received the AstraZeneca vaccine. All patients were diagnosed with GBS evidenced by nerve conduction studies and/or cerebrospinal fluid analysis.

Results:

The median age of the patients was 54.22 years (ranged 26–87 years), and seven patients were male. The patients were treated with Intravenous Immunoglobulin (IVIg) or Plasma Exchange (PLEX). All patients were discharged with some improvements.

Conclusion:

The link between the COVID-19 vaccine and GBS is not well understood. Given the prevalence of GBS over the population, this association may be coincidental; therefore, more studies are needed to investigate a causal relationship.

Predicting Mechanical Ventilation Using the EGRIS in Guillain-Barré Syndrome in a Latin American Country

BACKGROUND

Up to one fifth of patients with Guillain-Barré syndrome (GBS) require mechanical ventilation (MV). The Erasmus GBS Respiratory Insufficiency Score (EGRIS) is a clinical predictive model developed in Europe to predict MV requirements among patients with GBS. However, there are significant differences between the Latin American and European population, especially in the distribution of GBS subtypes. Therefore, determining if the EGRIS is able to predict MV in a Latin American population is of clinical significance.

METHODS

We retrospectively analyzed clinical and laboratory data of 177 patients with GBS in three Peruvian hospitals. We performed a multivariate logistic regression of the factors making up the EGRIS. Finally, we evaluated the EGRIS discrimination through a receiver operating characteristic curve and determined its calibration through a calibration curve and a Hosmer-Lemeshow test, a test used to determine the goodness of fit.

RESULTS

We found that 14.1% of our patients required MV. One predictive factor of a patient's need for early MV was the number of days between the onset of motor symptoms and hospitalization. The Medical Research Council sum score did not alter the likelihood of early MV. Bulbar weakness increased the likelihood without showing statistical significance. In contrast, facial weakness was a protective factor of it. The EGRIS was significantly higher in patients who required early MV than in those who did not (P = 0.018). It showed an area under the curve (AUC) of 0.63, with an insignificant Hosmer-Lemeshow test result.

CONCLUSIONS

Although the EGRIS was higher in patients who required early MV than in those who did not, it only showed a moderate discrimination capacity (AUC = 0.63). Facial weakness, an item of the EGRIS, was not found to be a predictive factor in our population. We suggest assessing whether these findings are due to subtype predominance and whether a modified version of the EGRIS could improve performance.

Large Outbreak of Guillain-Barré Syndrome, Peru, 2019

Outbreaks of Guillain-Barré syndrome (GBS) are uncommon. In May 2019, national surveillance in Peru detected an increase in GBS cases in excess of the expected incidence of 1.2 cases/100,000 population. Several clinical and epidemiologic findings call into question the suggested association between this GBS outbreak and Campylobacter.

A 30-Year-Old Man with Acute Motor Axonal Neuropathy Subtype of Guillain-Barré Syndrome Having Hepatitis A Virus Infection

Guillain-Barré syndrome (GBS) is an acute monophasic immune-mediated polyradiculoneuropathy. Here, we report a case of a young man with acute motor axonal neuropathy (AMAN) subtype of GBS having hepatitis A virus (HAV) infection.

A 30-year-old man with icterus was referred to emergency center of Razi Hospital. He complained of flu-like symptoms 10 days before the onset of icterus. Also, he suffered from gradual fatigue and weakness with dark urine. He experienced neurological symptoms of muscle paralysis (ascending from the legs to hands). Neurological consultant suspected GBS at the first step based on clinical examinations. He was candidate for five sessions of plasmapheresis. The ultrasonography revealed liver span 166 mm, which was greater than the normal range, with normal parenchymal echo. The gallbladder wall was thicker than normal and gallstone with lesion was not seen in different conditions. He was discharged after total improvement of neurological symptoms and muscular power. In addition, the results of International normalized ratio (INR), partial thromboplastin time (PTT), prothrombin time (PT), alkaline phosphatase (ALK), alanine aminotransferase (ALT) , aspartate aminotransferase (AST), bilirubin total and direct (Bil T, D) tests were normal after 2-month follow-up.

Although, acute viral infections such as hepatitis E virus (HEV) is common in patients with GBS; the possibility of HAV infection in patients with its risk factor should not be neglected.

Prevalence and outcomes of Guillain-Barré syndrome among pediatrics in Saudi Arabia: a 10-year retrospective study

BACKGROUND

Guillain-Barré syndrome (GBS) is a progressive acute form of paralysis most probably secondary to an immune-mediated process. GBS among Saudis has been seldom investigated, which leaves both clinicians and researchers with scarcity in knowledge. Therefore, this study aims to assess the prevalence and clinical prognosis of GBS among pediatrics admitted with acute paralysis at a large healthcare facility in Riyadh, Saudi Arabia.

METHODS

This retrospective study reviewed patients' medical records between 2005 and 2015. Eligible cases were children (<14 years old) admitted to the hospital complaining of acute paralysis and later diagnosed with one form or variant of GBS. Pearson's chi-square, Fisher's exact test, and binary logistic regression were employed to analyze the collected data.

RESULTS

The prevalence of GBS was 49%. The male-to-female ratio was 1.45:1. The mean ± standard deviation age was 7±3.7 years. There were 34 (69.4%) cases with progression to maximum paralysis in ≤2 weeks, while 15 (30.6%) cases occurred beyond 2 weeks. Males (n=24, 82.8%) were more likely to endure progression to maximum paralysis in ≤2 weeks after the disease onset, compared to females (n=10, 50%), P=0.014. All cases complaining of respiratory problems exhibited a progression to maximum paralysis in ≤2 weeks, compared to those with no respiratory problems, P=0.027. Residual paralysis at 60 days post disease onset was highly associated with GBS patients of age 8-14 years (n=15, 65.2%), compared to younger patients (n=8, 30.8%), P=0.016. Patients admitted in colder seasons (n=14, 63.6%) were more likely to suffer residual paralysis too, compared to those in warmer seasons (n=9, 33.3%), P=0.035. GBS cases who complained of facial weakness (n=9, 75%) and ocular abnormalities (n=10, 71.4%) were also more likely to endure residual paralysis at 60 days post disease onset, P=0.025 and P=0.03, respectively.

CONCLUSION

Male gender could be a determinant of rapid progression to maximum paralysis, while the older age group in pediatrics is expected to endure residual paralysis at 60 days post disease onset. GBS can be accounted as a rare disease, especially in pediatrics, so confirmed cases should be investigated comprehensively for research purposes.

Trapped in the epineurium: early entry into the endoneurium is restricted to neuritogenic T cells in experimental autoimmune neuritis

Background

Autoimmune polyneuropathies are acquired inflammatory disorders of the peripheral nervous system (PNS) characterized by inflammation, demyelination, and axonal degeneration. Although the pathogenesis has not been fully elucidated, T cells recognizing self-antigens are believed to initiate inflammation in a subgroup of patients. However, the route and time of T cell entry into the PNS have not yet been described in detail. In this study, we analyzed both kinetics as well as localization of retrovirally transfected green fluorescent protein (GFP)-expressing neuritogenic T lymphocytes in experimental autoimmune neuritis (EAN).

Methods

T lymphocytes obtained from rats following EAN induction by immunization with peripheral nerve protein peptide P2_55–78 were retrovirally engineered to express GFP. Non-specific T cells were negatively selected by in vitro restimulation, whereas GFP-expressing neuritogenic T cells (reactive to P2_55–78) were adoptively transferred into healthy rats (AT-EAN). Antigen-specific T cell tracking and localization was performed by flow cytometry and immunohistochemistry during the course of disease.

Results

After induction of autoimmune neuritis, P2-reactive T cells were detectable in the liver, spleen, lymph nodes, lung, peripheral blood, and the sciatic nerves with distinct kinetics. A significant number of GFP⁺ T cells appeared early in the lung with a peak at day four. In the peripheral nerves within the first days, GFP-negative T cells rapidly accumulated and exceeded the number of GFP-expressing cells, but did not enter the endoneurium. Very early after adoptive transfer, T cells are found in proximity to peripheral nerves and in the epineurium. However, only GFP-expressing neuritogenic T cells are able to enter the endoneurium from day five after transfer.

Conclusions

Our findings suggest that neuritogenic T cells invade the PNS early in the course of disease. However, neuritogenic T cells cross the blood-nerve barrier with a certain delay without preference to dorsal roots. Further understanding of the pathophysiological role of autoagressive T cells may help to improve therapeutic strategies in immune-mediated neuropathies.

Epidemiology and Clinical Features of Guillain-Barre Syndrome in Isfahan, Iran

Background:

Guillain-Barre syndrome (GBS) is an immune-mediated peripheral neuropathy. We compared clinical, laboratory characteristics, and disease course of GBS subtypes in a large group of Iranian patients in Isfahan.

Materials and Methods:

We collected data from patients who were admitted to Alzahra referral university Hospital, Isfahan, Iran with a diagnosis of GBS. In this population-based cross-sectional research, characteristic of 388 cases with GBS between 2010 and 2015 were studied.

Results:

The current study recruited 388 patients with GBS including 241 males (62.1%) and 147 females (37.9%) with a mean age of 42.78 ± 21.34. Patients with polyradiculopathy had the highest mean age of 55.12 ± 20.59 years, whereas the least age was seen in acute motor axonal neuropathy (AMAN) with the mean of 36.30 ± 18.71 years. The frequency of GBS witnessed the highest frequency in spring with 113 cases (29.1%) and winter with 101 cases (26%). Patients' electrodiagnostic findings indicated that the highest frequency pertained to AMSAN with 93 cases (24%), whereas the least frequent diagnosis was acute Polyradiculopathy with 8 cases (2.1%). Most of the patients did not have any infections (53.6%) and among patients with infections, AMSAN had the highest frequency (22.9%) and finally, patients with AMSAN and AMAN had a higher length of stay.

Conclusion:

The study demonstrated incidence, sex distribution, preceding infection, and surgery similar to previous studies. However, our data differs from a study in Tehran that showed acute inflammatory demyelinating polyradiculoneuropathy is more prevalent than other types and we found a seasonal preponderance in cold months, particularly in axonal types.

Epidemiology of Guillain-Barré Syndrome in Aruba

The epidemiology of Guillain-Barré syndrome (GBS) in tropical areas is different compared with developed countries. We investigated the epidemiology of GBS on the Caribbean island of Aruba. Data were collected retrospectively from all 36 patients hospitalized with GBS between 2003 and 2011 in Aruba. We observed a seasonal distribution of GBS cases with a peak in February. The incidence rate (IR) fluctuated heavily between individual years. The overall IR was 3.93/100,000, which is higher than that observed in developed countries. Serological studies indicated a possible relation of GBS cases with dengue virus infections. We also observed a relation between the annual number of dengue cases in Aruba and the number of GBS cases in the same year. We conclude that the epidemiology of GBS in tropical areas can be different from temperate climate regions and that dengue may be a trigger for developing GBS.

Guillain-BarrÉ Syndrome After Immunization in Canadian Children (1996-2012)

Guillain-Barré syndrome (GBS) cases admitted to Canadian pediatric tertiary care centers were ascertained through active surveillance. From 1996 to 2012, 246 cases were identified, and 24 (10%) had onset ≤30 days after immunization. Annual rate of postimmunization GBS was 2.0 per 100,000 hospitalizations. Postimmunization GBS was an infrequent cause of pediatric hospitalization.

Relationship Between Cerebrospinal Fluid Protein Levels and Electrophysiologic Abnormalities in Guillain-Barré Syndrome

OBJECTIVES

The cerebrospinal fluid (CSF) protein level is known to be elevated in patients with Guillain-Barré syndrome (GBS). This report correlates the degree of CSF protein elevation with the number of electrophysiologic abnormalities on nerve conduction study (NCS).

METHODS

We reviewed 38 patients admitted to our institution with a diagnosis of GBS and had both a measured CSF protein level and a NCS within 24 hours of each other.

RESULTS

CSF protein level correlates with the number of NCS demyelination criteria, as described by Cornblath, in patients with GBS.

CONCLUSIONS

This retrospective study is the first to demonstrate a relationship between the CSF protein level and the electrophysiologic abnormalities that accompany GBS.

Guillain-Barré syndrome

Guillain-Barré syndrome and its clinical variants are a group of rapidly progressing, potentially debilitating neurologic disorders that may have significant morbidity/mortality if left unrecognized or untreated. The most common symptoms include ascending limb weakness and paralysis, which may progress to respiratory failure. Diagnosis is made clinically with laboratory testing. Several treatment options exist, including plasma exchange and intravenous immunoglobulin administration. Most cases may resolve without sequelae, but those that do not may leave behind significant persistent debility.

Acute Flaccid paralysis in adults: Our experience

Acute flaccid paralysis (AFP) is a complex clinical syndrome with a broad array of potential etiologies that vary with age. We present our experience of acute onset lower motor neuron paralysis.

A retrospective survey of the quality of reports and their correlates among randomized controlled trials of immunotherapy for Guillain-Barré syndrome

AIM

This study aims to assess the quality of reports and their correlates in randomized controlled trials (RCTs) of immunotherapy for Guillain-Barré syndrome (GBS).

METHODS

A search was performed in multiple databases of reports published between April 1992 and November 2012. Reporting quality was assessed by items of the Consolidated Standards of Reporting Trials (CONSORT) 2010 Statement. An overall quality score (OQS) and a key methodological index score (MIS) were calculated for each trial. Factors associated with OQS and MIS were then identified.

RESULTS

A total of 19 RCTs were included in the full text. The median OQS was 7.0, with a range of 1-10. However, the quality of reporting in items of 'flow chart' and 'ancillary analyses' was poor with a positive rate of less than 40%. The median MIS was 0 with a range of 0-2. Twelve (63.2%) did not report any of the three key methodological items. Specifically, the mean OQS increased by approximately 2.73 for manuscripts published in the New England Journal of Medicine, The Lancet, Pediatrics and Neurology (95% CI: 0.35-5.12; p < 0.05). Multivariate linear regression and the Poisson regression model could not be presented as the number of included trials was too small.

CONCLUSION

The reporting quality in RCTs on immunotherapy for GBS was poor, which indicated that reporting in RCTs of immunotherapy for GBS needed substantial improvement in order to meet the guideline of the CONSORT Statement.

Pathogenesis of Guillain–Barré syndrome

Guillain-Barre syndrome is a postinfectious disorder caused by an aberrant immune response to an infectious pathogen, resulting in an autoimmune disease. As with other autoimmune diseases of infectious nature, the intricate balance of the numerous factors involved in the immune response may determine the outcome of the interaction between the microbe and host. Recent studies focusing on the role of cytokines and its network of related mediators and receptors suggest that any imbalance may make a significant contribution to the outcome of the infectious disease process. Better understanding of the pathogenesis of Guillain-Barre syndrome may lead to the discovery of newer therapeutics and may also serve as a model for studying other autoimmune diseases.

Guillain-Barré syndrome and adjuvanted pandemic influenza A (H1N1) 2009 vaccines: a multinational self-controlled case series in Europe

Background

The risk of Guillain-Barré syndrome (GBS) following the United States' 1976 swine flu vaccination campaign in the USA led to enhanced active surveillance during the pandemic influenza (A(H1N1)pdm09) immunization campaign. This study aimed to estimate the risk of GBS following influenza A(H1N1)pdm09 vaccination.

Methods

A self-controlled case series (SCCS) analysis was performed in Denmark, Finland, France, Netherlands, Norway, Sweden, and the United Kingdom. Information was collected according to a common protocol and standardised procedures. Cases classified at levels 1–4a of the Brighton Collaboration case definition were included. The risk window was 42 days starting the day after vaccination. Conditional Poisson regression and pooled random effects models estimated adjusted relative incidences (RI). Pseudo likelihood and vaccinated-only methods addressed the potential contraindication for vaccination following GBS.

Results

Three hundred and three (303) GBS and Miller Fisher syndrome cases were included. Ninety-nine (99) were exposed to A(H1N1)pdm09 vaccination, which was most frequently adjuvanted (Pandemrix and Focetria). The unadjusted pooled RI for A(H1N1)pdm09 vaccination and GBS was 3.5 (95% Confidence Interval (CI): 2.2–5.5), based on all countries. This lowered to 2.0 (95% CI: 1.2–3.1) after adjustment for calendartime and to 1.9 (95% CI: 1.1–3.2) when we accounted for contra-indications. In a subset (Netherlands, Norway, and United Kingdom) we further adjusted for other confounders and there the RI decreased from 1.7 (adjusted for calendar month) to 1.4 (95% CI: 0.7–2.8), which is the main finding.

Conclusion

This study illustrates the potential of conducting European collaborative vaccine safety studies. The main, fully adjusted analysis, showed that the RI of GBS was not significantly elevated after influenza A(H1N1)pdm09 vaccination (RI = 1.4 (95% CI: 0.7–2.8). Based on the upper limits of the pooled estimate we can rule out with 95% certainty that the number of excess GBS cases after influenza A(H1N1)pdm09 vaccination would be more than 3 per million vaccinated.

Recent developments and future directions in Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) encompasses a spectrum of acquired neuropathic conditions characterized by inflammatory demyelinating or axonal peripheral neuropathy with acute onset. Clinical and experimental studies in the past years have led to substantial progress in epidemiology, pathogenesis of GBS variants, and identification of prognostic factors relevant to treatment. In this review we provide an overview and critical assessment of the most recent developments and future directions in GBS research.

Chart-confirmed guillain-barre syndrome after 2009 H1N1 influenza vaccination among the Medicare population, 2009-2010

Given the increased risk of Guillain-Barré Syndrome (GBS) found with the 1976 swine influenza vaccine, both active surveillance and end-of-season analyses on chart-confirmed cases were performed across multiple US vaccine safety monitoring systems, including the Medicare system, to evaluate the association of GBS after 2009 monovalent H1N1 influenza vaccination. Medically reviewed cases consisted of H1N1-vaccinated Medicare beneficiaries who were hospitalized for GBS. These cases were then classified by using Brighton Collaboration diagnostic criteria. Thirty-one persons had Brighton level 1, 2, or 3 GBS or Fisher Syndrome, with symptom onset 1-119 days after vaccination. Self-controlled risk interval analyses estimated GBS risk within the 6-week period immediately following H1N1 vaccination compared with a later control period, with additional adjustment for seasonality. Our results showed an elevated risk of GBS with 2009 monovalent H1N1 vaccination (incidence rate ratio = 2.41, 95% confidence interval: 1.14, 5.11; attributable risk = 2.84 per million doses administered, 95% confidence interval: 0.21, 5.48). This observed risk was slightly higher than that seen with previous seasonal influenza vaccines; however, additional results that used a stricter case definition (Brighton level 1 or 2) were not statistically significant, and our ability to account for preceding respiratory/gastrointestinal illness was limited. Furthermore, the observed risk was substantially lower than that seen with the 1976 swine influenza vaccine.

Combination of AIDP and pyramidal signs associated with antecedent hepatitis A infection: a rare (co)occurrence

Guillain-Barré syndrome (GBS) is a postinfectious illness and commonly occurs in association with infective agents such as Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus, Mycoplasma pneumoniae, HIV, shigella, clostridium, Haemophilus influenzae; occasionally with acute hepatitis B, C, E; and more rarely with hepatitis A, as documented in various case reports. Classically, GBS presents with hyporeflexia or areflexia, but preserved and brisk reflexes have been described in context with GBS variant, AMAN (acute motor axonal neuropathy), in approximately 33% of the cases. Preserved or exaggerated tendon reflexes with extensor plantar response is not usually seen in patients with acute inflammatory demyelinating polyradiculoneuropathy (AIDP). We report a rare case of AIDP with upper motor neuron signs in association with an antecedent hepatitis A infection.

Guillain-Barré syndrome and variants

Guillain-Barré syndrome (GBS) is characterized by rapidly evolving ascending weakness, mild sensory loss, and hyporeflexia or areflexia. Acute inflammatory demyelinating polyneuropathy was the first to be recognized over a century ago and is the most common form of GBS. Axonal motor and sensorimotor variants have been described in the last three decades and are mediated by molecular mimicry targeting peripheral nerve motor axons. Other rare phenotypic variants have been recently described with pure sensory variant, restricted autonomic manifestations, and the pharyngeal-cervical-brachial pattern. It is important to recognize GBS and its variants because of the availability of equally effective therapies in the form of plasmapheresis and intravenous immunoglobulins.

The Guillain-Barré syndrome

The latest estimation for the frequency of Guillain-Barré syndrome (GBS) is 1.1 to 1.8 per 100000 persons per year. Guillain-Barré syndrome is today divided into two major subtypes: acute inflammatory demyelinating polyneuropathy (AIDP) and the axonal subtypes, acute motor axonal neuropathy (AMAN) and acute motor and sensory axonal neuropathy (AMSAN). The axonal forms of GBS are caused by certain autoimmune mechanisms, due to a molecular mimicry between antecedent bacterial infection (particularly Campylobacter jejuni) and human peripheral nerve gangliosides. Improvements in patient management in intensive care units has permitted a dramatic drop in mortality rates. Immunotherapy, including plasma exchange (PE) or intravenous immunoglobulin (IVIg), seems to shorten the time to recovery, but their effect remains limited. Further clinical investigations are needed to assess the effect of PE or IVIg on the GBS patients with mild affection, no response, or relapse.

[Guillain-Barré syndrome after exposure to influenza]

Guillain-Barré Syndrome (GBS) is an acquired, monophasic inflammatory polyradiculoneuritis of autoimmune origin, which occurs after infection and occasionally also after vaccination. Seasonal and pandemic influenza vaccines have in particular been implicated as triggers for GBS. However, a number of recent studies indicate that infection with influenza virus may also cause GBS. This review summarizes the epidemiological and experimental data of the association of GBS with exposure to influenza antigens by immunization (including vaccines against A/H1N1/2009) and infection. Vaccination against influenza is associated with a very low risk for the occurrence of GBS. In contrast infection with influenza may play a more important role as a triggering factor for GBS than previously assumed.

Spectrum of Guillain-Barré syndrome in tertiary care hospital at Kolkata

Objective:

In childhood Guillain–Barré syndrome (GBS), the clinical profiles using intravenous immunoglobulin (IVIg) in addition to supportive care were studied.

Materials and Methods:

This was a retrospective analysis of 139 children with severe GBS admitted to our respiratory care unit managed with the IVIg as an adjunct intervention to conventional supportive and respiratory care.

Results:

In our case series of 139 cases, motor weakness was the most common presenting feature. Antecedent illness was found in 66.7% of cases in the preceding two weeks, which included nonspecific illness, acute respiratory infection, diarrhea, and chickenpox. At onset, sensory symptoms (pain and paresthesia) were noted in 59% of the cases and limb weakness in 77%. On admission, a majority (61.54%) were in Hughes neurological disability grading stage V; all had limb weakness at the peak deficit, autonomic disturbance was seen in 35.8%, and bulbar palsy in 52%. Duration of illness was less than three weeks in 67% of cases. The mean duration of ventilation was 21.5 days (range, 5-60 days).

Conclusions:

Male preponderance and motor weakness was the most common presenting illness and a majority achieved full recovery in our series. Although IVIg may be useful in the treatment of GBS, the key issue is excellent intensive care unit management.

Guillain-Barré-like Syndrome, as a Rare Presentation of Adult T-cell Leukemia-Lymphoma (ATLL): A Case Report

We report a 21-year-old woman who was admitted because of unilateral facial paresis and then developed progressive ascending flaccid tetraparesis with generalized areflexia. Electrodiagnostic studies revealed acute motor axonal polyradiculoneuropathy (AMAN type of Guillain-Barré Syndrome). Further evaluations revealed severe leukocytosis, increased erythrocyte sedimentation rate (ESR), increased protein content and presence of a few lymphocytes in cerebrospinal fluid (CSF), and then presence of human T-cell lymphotropic virus type 1 (HTLV-I) in serum and CSF. Finally, biopsy of the enlarged lymph nodes resulted in the diagnosis of Adult T-cell Leukemia-Lymphoma. The HTLV-1 has been endemic to certain parts of Iran like Khorasan province in the northeast since 1985 with 2.3% prevalence rate of infection. Thus, some rare neurologic complications occasionally occur in this area as a result of being infected with HTLV-1.

Miller Fisher variant of Guillain-Barré syndrome masquerading as acute sphenoid sinusitis with orbital apex syndrome

Miller Fisher syndrome (MFS), a variant of Guillain-Barré syndrome, is a rare disorder typically characterized by a triad of ataxia, areflexia, and ophthalmoplegia, which may have a highly variable clinical presentation. We report a case of MFS in a 45-year-old female presenting with sphenoid sinusitis and sixth nerve palsy. She underwent endoscopic sphenoid sinusotomy without improvement, had postoperative deterioration, was diagnosed with MFS, and was treated with intravenous immunoglobulin with complete response. Because of the potential severity of Guillain-Barré syndrome, great vigilance should be taken when examining sixth nerve palsies to prevent misdiagnosis and delay in treatment of the MFS variant of this disease.

Guillain-Barré syndrome in Chinese children: a retrospective analysis

We reviewed the clinical and electrophysiologic features of 293 children with Guillain-Barré syndrome admitted to the Children's Hospital of Chongqing Medical University between 2000 and 2009. The male/female ratio was 2.02, and the syndrome occurred most frequently in those between 1 and 4 years of age. There was no seasonal variation. A total of 46.1% patients had experienced an infection 1 to 4 weeks before the onset of the syndrome. The main subtype was acute motor axonal neuropathy (50.0%), with acute inflammatory demyelinating polyradiculoneuropathy (38.1%) ranked as second in frequency. The mean motor disability score at nadir was 3.36 ± 1.00 for all patients, with mild variations among the different subgroups. No significant difference was found in age, seasonal occurrence, cerebrospinal fluid abnormality, and functional status at nadir between the acute motor axonal neuropathy and the acute inflammatory demyelinating polyradiculoneuropathy groups. A total of 36.5% patients had sensory symptoms at admission. Approximately 9.5% of patients required mechanical ventilation. Typical cytoalbuminologic dissociation at cerebrospinal fluid examination was demonstrated in 88.0% of those who underwent lumbar puncture.

Guillain-Barre syndrome, influenzalike illnesses, and influenza vaccination during seasons with and without circulating A/H1N1 viruses

The role of influenzalike illnesses and influenza vaccination in the development of Guillain-Barré syndrome (GBS), particularly the role of A/H1N1 epidemics and A/H1N1 vaccination, is debated. Data on all incident GBS cases meeting the Brighton Collaboration criteria that were diagnosed at 25 neurology centers in France were prospectively collected between March 2007 and June 2010, covering 3 influenzavirus seasons, including the 2009-2010 A/H1N1 outbreak. A total of 457 general practitioners provided a registry of patients from which 1,080 controls were matched by age, gender, index date (calendar month), and region to 145 cases. Causal relations were assessed by multivariate case-control analysis with adjustment for risk factors (personal and family history of autoimmune disorders, among others), while matching on age, gender, and calendar time. Influenza (seasonal or A/H1N1) or influenzalike symptoms in the 2 months preceding the index date was associated with GBS, with a matched odds ratio of 2.3 (95% confidence interval (CI): 0.7, 8.2). The difference in the rates of GBS occurring between influenza virus circulation periods and noncirculation periods was highly statistically significant (P = 0.004). Adjusted odds ratios for GBS occurrence within 6 weeks after seasonal and A/H1N1 vaccination were 1.3 (95% CI: 0.4, 4.1) and 0.9 (95% CI: 0.1, 7.6), respectively. Study results confirm that influenza virus is a likely risk factor for GBS. Conversely, no new concerns have arisen regarding influenza vaccination.

Pathogenesis and treatment of immune-mediated neuropathies

Immune-mediated neuropathies represent a heterogeneous spectrum of peripheral nerve disorders that can be classified according to time course, predominant involvement of motor/sensory fibers, distribution of deficits and paraclinical parameters such as electrophysiology and serum antibodies. In the last few years, significant advances have been achieved in elucidating underlying pathomechanisms, which made it possible to identify potential therapeutic targets. In this review, we discuss the latest development in pathogenesis and treatment of immune-mediated neuropathies.

Guillain-Barré syndrome as a prominent cause of childhood acute flaccid paralysis in post polio eradication era in Egypt

Guillain-Barré syndrome often follows an antecedent gastrointestinal or respiratory illness but, in rare cases, follows vaccination. This study was conducted to identify preceding events, demographic, clinical characteristics and prognostic factors of childhood Guillain-Barré syndrome after post-poliomyelitis eradication era in Egypt. This is a prospective study of all children with GBS (no = 50) admitted to pediatric Cairo University Hospital between January 2006 and June 2007 (70.42% of all acute flaccid paralysis patients during this period). Upper respiratory infection was the most common preceding event (24%) while only 4 patients (8%) reported antecedent oral polio vaccine. Motor deficit was frequent and severe (quadriparesis in 92% and paraparesis in 8%). Autonomic dysfunction was recorded in 32% of patients. Forty two percent of patients had poor outcome with 16% deaths. Presence of severe disability on admission and on nadir, cranial nerve affection or the need for mechanical ventilator were found to be significant predictors for poor outcome.