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Predictors of Mechanical Ventilation in Guillain-Barré Syndrome with Axonal Subtypes. Can J Neurol Sci 2023; 50:221-227. [PMID: 35189990 DOI: 10.1017/cjn.2022.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The early clinical predictors of respiratory failure in Latin Americans with Guillain-Barré syndrome (GBS) have scarcely been studied. This is of particular importance since Latin America has a high frequency of axonal GBS variants that may imply a worse prognosis. METHODS We studied 86 Mexican patients with GBS admitted to the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, a referral center of Mexico City, to describe predictors of invasive mechanical ventilation (IMV). RESULTS The median age was 40 years (interquartile range: 26-53.5), with 60.5% men (male-to-female ratio: 1.53). Most patients (65%) had an infectious antecedent (40.6% gastrointestinal). At admission, 38% of patients had a Medical Research Council (MRC) sum score <30. Axonal subtypes predominated (60.5%), with acute motor axonal neuropathy being the most prevalent (34.9%), followed by acute inflammatory demyelinating polyneuropathy (32.6%), acute motor sensory axonal neuropathy (AMSAN) (25.6%), and Fisher syndrome (7%). Notably, 15.1% had onset in upper limbs, 75.6% dysautonomia, and 73.3% pain. In all, 86% received either IVIg (9.3%) or plasma exchange (74.4%). IMV was required in 39.5% patients (72.7% in AMSAN). A multivariate model without including published prognostic scores yielded the time since onset to admission <15 days, axonal variants, MRC sum score <30, and bulbar weakness as independent predictors of IMV. The model including grading scales yielded lower limbs onset, Erasmus GBS respiratory insufficiency score (EGRIS) >4, and dysautonomia as predictors. CONCLUSION These results suggest that EGRIS is a good prognosticator of IMV in GBS patients with a predominance of axonal electrophysiological subtypes, but other early clinical data should also be considered.
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Halani S, Tombindo PE, O'Reilly R, Miranda RN, Erdman LK, Whitehead C, Bielecki JM, Ramsay L, Ximenes R, Boyle J, Krueger C, Willmott S, Morris SK, Murphy KE, Sander B. Clinical manifestations and health outcomes associated with Zika virus infections in adults: A systematic review. PLoS Negl Trop Dis 2021; 15:e0009516. [PMID: 34252102 PMCID: PMC8297931 DOI: 10.1371/journal.pntd.0009516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/22/2021] [Accepted: 05/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background Zika virus (ZIKV) has generated global interest in the last five years mostly due to its resurgence in the Americas between 2015 and 2016. It was previously thought to be a self-limiting infection causing febrile illness in less than one quarter of those infected. However, a rise in birth defects amongst children born to infected pregnant women, as well as increases in neurological manifestations in adults has been demonstrated. We systemically reviewed the literature to understand clinical manifestations and health outcomes in adults globally. Methods This review was registered prospectively with PROPSERO (CRD 42018096558). We systematically searched for studies in six databases from inception to the end of September 2020. There were no language restrictions. Critical appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools. Findings We identified 73 studies globally that reported clinical outcomes in ZIKV-infected adults, of which 55 studies were from the Americas. For further analysis, we considered studies that met 70% of critical appraisal criteria and described subjects with confirmed ZIKV. The most common symptoms included: exanthema (5,456/6,129; 89%), arthralgia (3,809/6,093; 63%), fever (3,787/6,124; 62%), conjunctivitis (2,738/3,283; 45%), myalgia (2,498/5,192; 48%), headache (2,165/4,722; 46%), and diarrhea (337/2,622; 13%). 36/14,335 (0.3%) of infected cases developed neurologic sequelae, of which 75% were Guillain-Barré Syndrome (GBS). Several subjects reported recovery from peak of neurological complications, though some endured chronic disability. Mortality was rare (0.1%) and hospitalization (11%) was often associated with co-morbidities or GBS. Conclusions The ZIKV literature in adults was predominantly from the Americas. The most common systemic symptoms were exanthema, fever, arthralgia, and conjunctivitis; GBS was the most prevalent neurological complication. Future ZIKV studies are warranted with standardization of testing and case definitions, consistent co-infection testing, reporting of laboratory abnormalities, separation of adult and pediatric outcomes, and assessing for causation between ZIKV and neurological sequelae. Interest in Zika virus (ZIKV) has increased in the last decade due to its emergence and rapid spread in the Americas. In this review, we examine ZIKV clinical manifestations and sequelae in adults. Among studies reporting subjects with confirmed ZIKV and critical appraisal scores of at least 70%, symptoms reported include exanthema, fever, arthralgia, conjunctivitis, myalgia, headache, and diarrhea. Neurological sequelae in this group occurred in 0.3% of subjects, of which 75% were Guillain-Barré Syndrome (GBS). Recovery from GBS was variable: some patients returned to health and others endured chronic disability. Mortality was rare (0.1%). Hospitalization (11%) was often associated co-morbidities or GBS; this percentage perhaps reflects studies in which all reported subjects were hospitalized. Synthesizing reported data is challenging given the wide range of case definitions and ZIKV testing practices.
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Affiliation(s)
| | | | - Ryan O'Reilly
- University of Toronto, Toronto, Ontario, Canada.,Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Rafael N Miranda
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Laura K Erdman
- University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Clare Whitehead
- University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia.,Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Joanna M Bielecki
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Lauren Ramsay
- University of Toronto, Toronto, Ontario, Canada.,Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Raphael Ximenes
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada.,Escola de Matemática Aplicada, Fundação Getúlio Vargas, Praia de Botafogo, Rio de Janeiro, Brasil
| | | | - Carsten Krueger
- University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shannon Willmott
- University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shaun K Morris
- University of Toronto, Toronto, Ontario, Canada.,Division of Infectious Diseases, Hospital for Sick Children, Toronto, Ontario, Canada.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kellie E Murphy
- University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Beate Sander
- University of Toronto, Toronto, Ontario, Canada.,Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada.,Public Health Ontario, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Zika and dengue but not chikungunya are associated with Guillain-Barré syndrome in Mexico: A case-control study. PLoS Negl Trop Dis 2020; 14:e0008032. [PMID: 33332366 PMCID: PMC7775118 DOI: 10.1371/journal.pntd.0008032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 12/31/2020] [Accepted: 10/05/2020] [Indexed: 11/19/2022] Open
Abstract
Background Zika, dengue and chikungunya viruses (ZIKV, CHIKV and DENV) are temporally associated with neurological diseases, such as Guillain-Barré syndrome (GBS). Because these three arboviruses coexist in Mexico, the frequency and severity of GBS could theoretically increase. This study aims to determine the association between these arboviruses and GBS in a Mexican population and to establish the clinical characteristics of the patients, including the severity of the infection. A case-control study was conducted (2016/07/01-2018/06/30) in Instituto Mexicano del Seguro Social (Mexican Social Security Institute) hospitals, using serum and urine samples that were collected to determine exposure to ZIKV, DENV, CHIKV by RT-qPCR and serology (IgM). For the categorical variables analysis, Pearson’s χ2 or Fisher exact tests were used, and the Mann-Whitney U test for continuous variables. To determine the association of GBS and viral infection diagnosis through laboratory and symptomatology before admission, we calculated the odds ratio (OR) and 95% confidence intervals (95%CI) using a 2x2 contingency table. A p-value ≤ 0.05 was considered as significant. Ninety-seven GBS cases and 184 controls were included. The association of GBS with ZIKV acute infection (OR, 8.04; 95% CI, 0.89–73.01, p = 0.047), as well as laboratory evidence of ZIKV infection (OR, 16.45; 95% CI, 2.03–133.56; p = 0.001) or Flavivirus (ZIKV and DENV) infection (OR, 6.35; 95% CI, 1.99–20.28; p = 0.001) was observed. Cases of GBS associated with ZIKV demonstrated a greater impairment of functional status and a higher percentage of mechanical ventilation. According to laboratory results, an association between ZIKV or ZIKV and DENV infection in patients with GBS was found. Cases of GBS associated with ZIKV exhibited a more severe clinical picture. Cases with co-infection were not found. Dengue (DENV), chikungunya (CHIKV), and Zika (ZIKV) are considered as emerging or re-emerging viruses. Recently, these viruses have produced major epidemics in tropical climate urban centers, and have been associated with neurological manifestations, including Guillain-Barre syndrome (GBS), which causes muscle weakness, unstable gait, and decreased or absent musculoskeletal reflexes. This study aims to investigate the association between these viral infections and GBS. A case and control study was conducted nationwide, including 97 cases of GBS and 184 controls matched by age, gender, and locality, but not the disease. The study shows a positive association between GBS cases and ZIKV or ZIKV and DENV infection. GBS cases associated with ZIKV depicted a more severe clinical picture (more impairment of functional status, incapacity, and a higher percentage of mechanical ventilation). Finally, the symptoms of suspected ZIKV disease prior to the development of GBS were similar to some previous reports. The impact of the interaction of these three arboviruses, particularly ZIKV, on the health of the Mexican population was less than expected. The Mexican experience could be useful for other populations.
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Leonhard SE, Halstead S, Lant SB, Militão de Albuquerque MDFP, de Brito CAA, de Albuquerque LBB, Ellul MA, de Oliveira França RF, Gourlay D, Griffiths MJ, de Miranda Henriques-Souza AM, de Morais Machado MÍ, Medialdea-Carrera R, Mehta R, da Paz Melo R, Mesquita SD, Moreira ÁJP, Pena LJ, Santos ML, Turtle L, Solomon T, Willison HJ, Jacobs BC, Brito Ferreira ML. Guillain-Barré syndrome during the Zika virus outbreak in Northeast Brazil: An observational cohort study. J Neurol Sci 2020; 420:117272. [PMID: 33360425 DOI: 10.1016/j.jns.2020.117272] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/30/2020] [Accepted: 12/11/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the clinical phenotype of Guillain-Barré syndrome (GBS) after Zika virus (ZIKV) infection, the anti-glycolipid antibody signature, and the role of other circulating arthropod-borne viruses, we describe a cohort of GBS patients identified during ZIKV and chikungunya virus (CHIKV) outbreaks in Northeast Brazil. METHODS We prospectively recruited GBS patients from a regional neurology center in Northeast Brazil between December 2014 and February 2017. Serum and CSF were tested for ZIKV, CHIKV, and dengue virus (DENV), by RT-PCR and antibodies, and serum was tested for GBS-associated antibodies to glycolipids. RESULTS Seventy-one patients were identified. Forty-eight (68%) had laboratory evidence of a recent arbovirus infection; 25 (52%) ZIKV, 8 (17%) CHIKV, 1 (2%) DENV, and 14 (29%) ZIKV and CHIKV. Most patients with a recent arbovirus infection had motor and sensory symptoms (72%), a demyelinating electrophysiological subtype (67%) and a facial palsy (58%). Patients with a recent infection with ZIKV and CHIKV had a longer hospital admission and more frequent mechanical ventilation compared to the other patients. No specific anti-glycolipid antibody signature was identified in association with arbovirus infection, although significant antibody titres to GM1, GalC, LM1, and GalNAc-GD1a were found infrequently. CONCLUSION A large proportion of cases had laboratory evidence of a recent infection with ZIKV or CHIKV, and recent infection with both viruses was found in almost one third of patients. Most patients with a recent arbovirus infection had a sensorimotor, demyelinating GBS. We did not find a specific anti-glycolipid antibody signature in association with arbovirus-related GBS.
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Affiliation(s)
- Sonja E Leonhard
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands.
| | - Susan Halstead
- Department of Neurology and Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Suzannah B Lant
- National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | | | | | | | - Mark A Ellul
- National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Dawn Gourlay
- Department of Neurology and Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Michael J Griffiths
- National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | | | - Raquel Medialdea-Carrera
- National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Ravi Mehta
- National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | | | | | | | - Lindomar J Pena
- Department of Virology, Institute Aggeu Magalhães (CPqAM), Oswaldo Cruz Foundation (Fiocruz), Recife, Brazil
| | - Marcela Lopes Santos
- Department of Collective Health, Institute Aggeu Magalhães (CPqAM), Oswaldo Cruz Foundation (Fiocruz), Recife, Brazil
| | - Lance Turtle
- National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Tom Solomon
- National Institute for Health Research Health Protection Research Unit on Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Hugh J Willison
- Department of Neurology and Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Bart C Jacobs
- Department of Neurology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Immunology, Erasmus University Medical Center, Rotterdam, Netherlands
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