Pain during the acute phase of Guillain-Barré syndrome

A 73-Year-Old Man Presenting with Shoulder Muscle Pain and a Diagnosis of Guillain-Barré Syndrome

BACKGROUND Guillain-Barre syndrome (GBS) commonly presents with motor weakness and neurological symptoms and signs that include loss of tendon reflexes. However, patients with GBS also experience nerve pain (radicular pain) and deep muscle pain. This report is of a 73-year-old man presenting with shoulder muscle pain and a diagnosis of Guillain-Barre syndrome. CASE REPORT A 73-year-old man initially sought medical attention for severe left shoulder muscle pain. One week prior, he had experienced a cold and diarrhea, which improved with over-the-counter medication. Physical examination revealed normal shoulder joint motion without swelling or stiffness. Cervical spine magnetic resonance imaging (MRI) revealed osteophytes and disc protrusions from C3/4 to C6/7, leading to an initial diagnosis of cervical spondylosis. Two days later, he developed progressive numbness and weakness in both upper limbs. Upon hospital admission, further evaluation revealed partial cranial nerve dysfunction, elevated cerebrospinal fluid (CSF) protein levels without pleocytosis, and peripheral nerve damage on electromyography (EMG). GM1 antibody was positive, confirming GBS. Treatment with intravenous immunoglobulin (IVIG), gabapentin for pain management, and acupuncture targeting pain and limb symptoms resulted in the complete recovery of pain and limb function within a short period. CONCLUSIONS This report shows that deep muscle pain can be a symptom of Guillain-Barre syndrome. Recognizing such atypical presentations is crucial for timely diagnosis and effective management. This case provides a clinical basis for the diagnosis of atypical GBS and offers insights into pain management in GBS.

The Role of Phytochemicals in Managing Neuropathic Pain: How Much Progress Have We Made?

Neuropathic pain is a complex and debilitating condition resulting from nerve damage, characterized by sensations such as burning, tingling, and shooting pain. It is often associated with conditions such as multiple sclerosis (MS), Guillain-Barré syndrome (GBS), and diabetic polyneuropathy. Conventional pain therapies frequently provide limited relief and are accompanied by significant side effects, emphasizing the need to explore alternative treatment options. Phytochemicals, which are bioactive compounds derived from plants, have gained attention for their potential in neuropathic pain management due to their diverse pharmacological properties, including anti-inflammatory, antioxidant, and neuroprotective effects. This review evaluates the mechanisms by which specific phytochemicals, such as curcumin, resveratrol, and capsaicin, influence neuropathic pain pathways, particularly their role in modulating inflammatory processes, reducing oxidative stress, and interacting with ion channels and signaling pathways. While curcumin and resveratrol are primarily considered dietary supplements, their roles in managing neuropathic pain require further clinical investigation to establish their efficacy and safety. In contrast, capsaicin is an active ingredient derived from chili peppers that has been developed into approved topical treatments widely used for managing neuropathic and musculoskeletal pain. However, not all phytochemicals have demonstrated consistent efficacy in managing neuropathic pain, and their effects can vary depending on the compound and the specific condition. The pathophysiology of neuropathic pain, involving maladaptive changes in the somatosensory nervous system, peripheral and central sensitization, and glial cell activation, is also outlined. Overall, this review emphasizes the need for continued high-quality clinical studies to fully establish the therapeutic potential of phytochemicals in neuropathic pain management.

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.

Case report and literature review: Acute rhabdomyolysis caused by overheating of electric blanket complicated with Guillain-Barré syndrome

Rhabdomyolysis (RM) induced by electric blankets is exceedingly rare, with only three cases identified in our literature review. Both RM and Guillain-Barré syndrome (GBS) present with similar clinical manifestations of myalgia and muscle weakness, posing a potential challenge for accurate diagnosis in clinical settings. This report presents the case of a 22-year-old man who developed RM subsequent to the use of an electric blanket. Despite undergoing plasma exchange and renal replacement therapy, the patient continued to exhibit poor muscle strength in both lower limbs. Subsequent comprehensive evaluation revealed the presence of concurrent GBS. Following a 5-day course of intravenous gamma globulin treatment, the patient experienced rapid recovery of muscle strength and was discharged. Additionally, we reviewed seven cases from the literature of coexistent RM and GBS. This indicated that investigation of the timing of onset of muscle strength decline in RM patients could help to identify potential concurrent neurological or muscular disorders. In cases in which concurrent GBS and RM cannot be definitively ascertained during early hospitalization, prioritizing plasma exchange treatment may lead to improved patient outcomes.

Neuropathic Pain in the Emergency Setting: Diagnosis and Management

Neuropathic pain, traditionally considered a chronic condition, is increasingly encountered in the emergency department (ED), accounting for approximately 20% of patients presenting with pain. Understanding the physiology and key clinical presentations of neuropathic pain is crucial for ED physicians to provide optimal treatment. While diagnosing neuropathic pain can be challenging, emphasis should be placed on obtaining a comprehensive medical history and conducting a thorough clinical examination. Patients often describe neuropathic pain as a burning or shock-like sensation, leading them to seek care in the ED after ineffective relief from common analgesics such as paracetamol and NSAIDs. Collaboration between emergency medicine specialists, neurologists, and pain management experts can contribute to the development of evidence-based guidelines specifically tailored for the emergency department setting. This article provides a concise overview of the common clinical manifestations of neuropathic pain that may prompt patients to seek emergency care.

Guillain-Barré Syndrome Presenting as Painful Weakness and Edema of the Legs: A Case Report

Guillain-Barré syndrome (GBS) is an autoimmune inflammatory polyneuropathy, which can be challenging to diagnose due to variability in the initial presenting features. Pain, flaccid paresis, motor sensory disturbance, hyporeflexia, and autonomic dysfunction are the typical manifestations, although atypical features, such as ataxia, neck stiffness, dysphagia, ophthalmoplegia, bulbar palsy, and isolated upper limb weakness, may be seen. It may also progress to fatal respiratory depression. As such, timely diagnosis and treatment are essential. We present the case of a 41-year-old man who presented with a four-day history of acute-onset bilateral lower extremity swelling, decreased motor strength, diffuse muscle pain, hyporeflexia, and absent vibratory sensation. After admission, symptoms worsened, and the patient developed new-onset swallowing difficulty and urinary retention. Neurological examination findings of hyporeflexia and flaccid paralysis, along with normal thyroid function, and the absence of cord compression on spinal MRI pointed toward the diagnosis of GBS. Nerve conduction studies (NCS) and concentric electromyography (EMG) confirmed the diagnosis. The patient was treated with intravenous immune globulin (IVIG) and eventually discharged to a rehabilitation facility after a 12-day hospital stay. Later, the patient developed contractures and chronic pain consistent with post-GBS syndrome, for which we referred him for pain management and physical therapy. A rapidly progressive weakness with autonomic dysfunction should prompt suspicion of GBS and should be treated with intravenous immunoglobulins or plasma exchange without further delay.

Bupivacaine and morphine epidural use for refractory neuropathic pain relief in a Guillain-Barré syndrome patient

Pain is common in the acute phase of Guillain-Barré Syndrome and can be severe and refractory. Pain in GBS may not always respond to contemporary pain therapy. An epidural can potentially be considered for the treatment of refractory pain after a careful patient-centered discussion with the patient about risks.

Sural Sparing Pattern and Sensory Ratio as Electrodiagnostic and Prognostic Markers in Pediatric Guillain-Barré Syndrome

BACKGROUND

We aimed to evaluate the presence of sural sparing pattern (SSP) and sensory ratio in pediatric Guillain-Barré syndrome (GBS), their distribution to subtypes, and their relationship with demographic and clinical features with a focus on the disability and muscle strength.

METHODS

This single-center retrospective study was conducted on pediatric GBS patients of both sexes with 2 years follow-up and two nerve conduction studies in which SSP and sensory ratio were calculated. Three subgroups of SSP were formed by separate calculation of median (SSP-m) and ulnar (SSP-u) and both median and ulnar sensory nerve action potentials (SNAPs; SSP-total). Muscle strength and disability were evaluated with the Medical Research Council (MRC) sum score and Hughes functional grading scale (HFGS), respectively.

RESULTS

SSP total was identified in 70.6% (n: 24) of the patients, while sensory ratio >1 was observed in 20 (66.7%) patients. Patients with SSP-m, SSP-u, SSP-total, or sensory ratio >1 had higher HFGS scores, while patients with SSP-m, SSP-u, or SSP-total had lower MRC sum scores. SSP parameters were significantly associated with muscle strength and disability scores in acute motor axonal neuropathy patients.

CONCLUSION

Both SSP and sensory ratio can be used for diagnostic and prognostic purposes. Disability and muscle strength are associated with SSP and sensory ratio in pediatric GBS.

Abdominal Pain Followed by Altered Mental Status: A Rare Presentation of Guillain Barré Syndrome

Guillain Barré syndrome (GBS) is an acute inflammatory polyneuropathy with several variants; it usually presents as acute symmetrical muscle weakness with or without bulbar involvement, making it a neurological emergency. In this report, we describe the case of a 39-year-old male who presented with abdominal pain for three days and whose illness became progressively drowsy on the fifth day. Based on clinical assessment, nerve conduction studies, and biochemical, microbiological, and radiological investigations, other causes were ruled out and it was concluded that the patient had hyponatremia secondary to syndrome of inappropriate diuretic hormone secretion (SIADH) due to GBS.

Although sensory symptoms like pain or dysaesthesias occurring in the back or extremities are common and may precede motor weakness, abdominal pain remains a very rare presentation of GBS. GBS is usually understood as a “pure” peripheral nervous system disorder but central nervous system (CNS) dysfunction may occur due to metabolic abnormalities (like hyponatremia and CO₂ narcosis) or autonomic dysfunction in GBS, its treatment, or due to GBS itself (Anti-GQ1b disease variant).

Old age and multiple comorbidity are associated with delayed diagnosis of Guillain-Barre syndrome

To assess whether older age and presence of comorbidities were associated with a delayed diagnosis of Guillain-Barré syndrome (GBS). The medical records of 140 patients diagnosed with GBS at Severance Hospital from March 2011 to December 2020 were retrospectively reviewed. Comorbidity profiles were assessed using the Charlson comorbidity index (CCI). The age-adjusted CCI (ACCI) score was calculated, which further incorporated the effect of age. Patients were classified into the early diagnosis group (diagnosis duration ≤ 14 days) and late diagnosis group (diagnosis duration > 14 days). Clinical features and comorbidity profiles were compared between the two groups. The cumulative incidence of diagnosis was compared between the low and high ACCI groups. Age was significantly higher in the late diagnosis group (61.8 ± 15.0 years) than in the early diagnosis group (49.1 ± 18.4, p = 0.001). The CCI score was higher in the late diagnosis group (≥ 3 in 26.1%) than in the early diagnosis group (≥ 3 in 5.1%, p = 0.01). The ACCI score demonstrated a positive correlation with the diagnosis duration (β = 1.636, p < 0.001), indicating that the diagnosis was delayed in patients with a higher ACCI score. The duration from onset to diagnosis was longer in the high ACCI group than in the low ACCI group (log-rank test, p < 0.001). The diagnosis duration was significantly longer, especially in patients with malignancy and cardiovascular diseases. Delayed diagnosis of GBS is associated with older age and multiple comorbidities. Diagnostic delay was significant in patients with malignancies and cardiovascular diseases. Early suspicion of GBS is required in these patients.

Transient Receptor Potential Vanilloid 1 (TRPV1) as a plausible novel therapeutic target for treating neurological complications in ZikaVirus

Zika virus was declared a national emergency by WHO (World Health Organization) in 2016 when its widespread outbreaks and life-threatening complications were reported, especially in newborns and adults. Numerous studies reported that neuroinflammation is one of the significant root-causes behind its major neurological complications like microcephaly and Guillain-Barré syndrome (GBS). In this hypothesis, we propose Transient Receptor Potential Vanilloid 1 channel (TRPV1) as a major culprit in triggering positive inflammatory loop, ultimately leading to sustained neuroinflammation, one of the key clinical findings in Zika induced microcephalic and GBS patients. Opening of TRPV1 channel also leads to calcium influx and oxidative stress that ultimately results in cellular apoptosis (like Schwann cell in GBS and developing fetal nerve cells in microcephaly), ultimately leading to these complications. Currently, no specific cure exists for these complications. Most of the antiviral candidates are under clinical trials. Though there is no direct research on TRPV1 as a cause of Zika virus's neurological complications, but similarity in mechanisms is undeniable. Thus, exploring pathobiological involvement of TRPV1 channels and various TRPV1 modulators in these complications can possibly prove to be an effective futuristic therapeutic strategy for treatment and management of these life-threatening complications.

Pain in acute motor axonal neuropathy

INTRODUCTION/AIMS

Patients with acute motor axonal neuropathy (AMAN) generally have pure motor neuropathy and clinicians usually do not link pain with AMAN. The aim of this retrospective study was to describe the character, location, and intensity of pain in AMAN and acute inflammatory demyelinating polyneuropathy (AIDP) in the acute phase.

METHODS

This was a retrospective study in 44 patients with Guillain-Barré syndrome (GBS) having progressive weakness of more than one limb. The information, including the demographic characteristics, preceding infections, clinical symptoms and signs, severity at nadir, the characteristics of pain, use of analgesics, laboratory and electrophysiological data, and the medical treatment for GBS, were collected from the medical records.

RESULTS

In 44 patients, 40.9% were diagnosed as AMAN, and 34.1% as AIDP. Pain was more prevalent in AMAN (76.5%) than in AIDP (26.7%, P = .02). Low back and extremities were the most common locations of pain in AMAN (7/13 and 7/13, respectively) and AIDP (2/4 and 2/4, respectively).

DISCUSSION

Pain was a common symptom in AMAN in the acute stage. The presence or absence of pain is not useful for distinguishing AIDP from AMAN.

Neuropathic Pain in Guillain-Barre Syndrome: Association with Rehabilitation Outcomes and Quality of Life

BACKGROUND

Neuropathic pain contributes significantly to the morbidity and affects the quality of life adversely in Guillain-Barre syndrome (GBS).

OBJECTIVE

To study neuropathic pain profile in GBS and association with rehabilitation outcomes and effect on the quality of life.

METHODS

Observational study conducted in rehabilitation setting of a tertiary care hospital among adult GBS patients of less than 3 months duration. Assessment was done at the time of admission and discharge with Pain-detect questionnaire (PD-Q), Neuropathic pain scale (NPS), SF 36 survey, Medical Research Council (MRC) score, INCAT sensory sum score (ISS), Overall Disability sum-score (ODSS), Hughes disability score (HDS), Hospital Anxiety and Depression scale (HADS), and Fatigue Severity scale (FSS). Neuropathic pain was managed as per routine protocol and rehabilitation program was individualized.

RESULTS

32 participants (26 males) with median age of 34.50 years were included. Eighteen (56.25%) patients had neuropathic pain on PD-Q at admission. The median intensity of pain on NPS scale was 47 at admission which decreased significantly to 14 at discharge. Pain group showed significant association with sensory impairment, CSF protein, and emotional domains of QOL while no association with disability.

CONCLUSION

Neuropathic pain is associated with sensory impairment in GBS and markedly affects the quality of life, especially emotional, family, and social activities.

Rare Organism Uncommon Disease Case Vignette of Guillain-Barré Syndrome Induced by Fusobacterium nucleatum Infection

In this case report, we describe an unusual pathogen F. nucleatum-induced empyema, followed by the development of Guillain–Barré syndrome (GBS). Although many pathogens have been associated with GBS, this may be one of the few in the literature to describe an association with F. nucleatum infection.

Masquerading Guillain-Barré syndrome: uncommon, in-hospital presentation of Miller-Fisher syndrome shadowed by secondary diseases

Presentation of severe pain syndromes prior to onset of motor weakness is an uncommon but documented finding in patients with Guillain-Barré syndrome (GBS). Sciatica in GBS is a difficult diagnosis when patients present with acute radiculopathy caused by herniated disc or spondylolysis. A middle-aged woman was admitted for severe low back pain, symptomatic hyponatraemia, vomiting and constipation. On further investigation, she was diagnosed with radiculopathy, and appropriate treatment was initiated. Brief symptomatic improvement was followed by new-onset weakness in lower limbs, which progressed to involve upper limbs and right extraocular muscles. With progressive, ascending, new-onset motor and sensory deficits and laboratory evidence of demyelination by Nerve Conduction Study, a diagnosis of variant GBS was made. She was treated with intravenous immunoglobulin 2 g/kg over 5 days. The presentation of severe low back pain that was masking an existing aetiology and possible dysautonomia and the unilateral right extraocular muscles instead of bilateral make our case unique and rare.

Longitudinal study of neuropathic pain in patients with Guillain-Barré syndrome

OBJECTIVE

The aim of this study was to analyze neuropathic pain (NeP) and its therapy in patients with Guillain-Barré syndrome (GBS) during a 6-month follow-up period.

METHOD

This longitudinal multicenter study included 69 newly diagnosed adult GBS patients. NeP diagnosis was based on the criteria of Finnerup and confirmed by the PainDETECT Questionnaire (PD-Q). Severity of GBS was assessed by GBS disability scale (GDS). Patients were assessed: on day 14 (D14), day 28 (D28), month 3 (M3), and month 6 (M6) from the disease onset.

RESULTS

At D14, pain was present in 85.5% of patients, while 26.4% had NeP. At M6, 72.5% of patients had pain, 20.0% of them NeP. In acute GBS, pain intensity was higher in patients with NeP compared to those with non-NeP (p < 0.01). Pain intensity in patients with NeP did not change during time, but it decreased in patients with non-NeP at M6 (p < 0.05). Around 20% of GBS patients were on specific NeP medication throughout the observed period. One quarter of patients with NeP were not on specific NeP drug in the acute phase. Up to one third of patients with NeP were on NeP medication but still had significant NeP. Pooled PD-Q score was in correlation with pooled GDS score (rho = + 0.43, p < 0.01).

CONCLUSIONS

NeP is a common and potentially severe symptom in GBS that may persist for months. It is important to recognize NeP, start specific treatment on time, in adequate doses, and for prolonged period of time.

Synthetic melanin nanoparticles as peroxynitrite scavengers, photothermal anticancer and heavy metals removal platforms

Melanin is a ubiquitous natural polyphenolic pigment with versatile applications including physiological functions. This polymeric material is found in a diversity of living organisms from bacteria to mammals. The biocompatibility and thermal stability of melanin nanoparticles make them good candidates to work as free radical scavengers and photothermal anticancer substrates. Research studies have identified melanin as an antioxidative therapeutic agent and/or reactive oxygen species (ROS) scavenger that includes neutralization of peroxynitrite. In addition, melanin nanoparticles have emerged as an anticancer photothermal platform that has the capability to kill cancer cells. Recently, melanin nanoparticles have been successfully used as chelating agents to purify water from heavy metals, such as hexavalent chromium. This review article highlights some selected aspects of cutting-edge melanin applications. Herein, we will refer to the recent literature that addresses melanin nanoparticles and its useful physicochemical properties as a hot topic in biomaterial science. It is expected that the techniques of Dynamic Light Scattering (DLS), Scanning Electron Microscopy (SEM), and time-resolved Electron Paramagnetic Resonance (EPR) will have a strong impact on the full characterization of melanin nanoparticles and the subsequent exploration of their physiological and chemical mechanisms.

Disability and quality of life in Guillain-Barré syndrome - Longitudinal study

Longitudinal health-related quality of life (QoL) data in Guillain-Barré (GBS) patients are still scarce. We, therefore, investigated health- related QoL in GBS patients from Serbia and surrounding countries during a six-month follow-up period, and analyzed its association with patients' disability. Our study comprised 74 adult patients diagnosed with GBS from May 2017 until May 2018 in seven tertiary healthcare centers. Health-related QoL was investigated using the SF-36 questionnaire, and compared with functional disability assessed by the GBS disability scale (GDS). Tests were performed at day 14, day 28, month 3 and month 6 from disease onset. GDS and SF-36 scores improved over time (p < 0.01). GDS scores were different at all four time points, while SF-36 did not differ between day 14 and day 28. Pooled SF-36 scores (especially physical ones) correlated with pooled GDS scores, except for Bodily Pain and Role Emotional scores. We found that GDS score at day 14 was an independent predictor of GDS score at month 6 (β = +0.52, p < 0.01), while SF-36 score at day 14 was an independent predictor of SF-36 score at month 6 (β = +0.51, p < 0.01). Neurologists should look not only on disability but also on QoL in GBS patients, since these two measures provide us with important complementary items of information.

Guillain-Barré syndrome in a heart transplantation recipient

ABSTRACT

A rare case of a heart transplantation recipient with Guillain-Barré syndrome occurred, which was associated with peripheral nervous system damage. Based on a review of epidemiological research, the symptom development process, and diagnostic tools, the authors highlight the extreme rarity of this postinfectious immune disease. After diagnosis, plasma exchange and immunoregulatory therapy should be performed because they result in rapid recovery. If there is delayed diagnosis and treatment, there is a high risk of disability or death. When patients experience acute limb paralysis as the main symptom, nurse practitioners (NPs) should focus on the patient's history, particularly with regard to infectious agents. Closely monitoring the patient to detect respiratory failure and the need for early respiratory intervention can help the patient to avoid the severe complication of permanent brain injury. For NPs, performance of early differential diagnosis is important, especially among patients who have immunosuppressive dependence after transplantation.