Ralstoniapickettii bloodstream infection in the patient with Guillain-Barre syndrome under plasmapheresis

Ralstonia pickettii is a rare Gram-negative opportunistic bacterium that causes rare infections such as bacteremia, neonatal sepsis, endocarditis, and meningitis in hospitalized or immunocompromised patients. In this study, we identified and reported bloodstream infection caused by R. pickettii in a 15 -year-old boy patient with an autoimmune disease, Guillain-Barré syndrome, under plasmapheresis and intravenous immune globulin (IVIG) therapy. He was referred for admission to the neurology center of the teaching hospital of Shiraz, Iran for inability to walk, and lower extremity muscle weakness. After he was treated with plasmapheresis once during hospitalization, and after severe fever besides shivering blood cultures using BACT/ALERT®3D instrument were positive for R. pickettii.According to antibiotic susceptibility test reports, Ciprofloxacin (5 μg) was prescribed. Fortunately, after starting antibiotic treatment, blood culture results reported no growth after 5 days. Indeed, the patient was infected with nosocomial hepatitis A and URSOBIL (300 mg/BID/Po) was administered. Hence, after reporting the infection occurrence to the hospital infection control unit, initial and possible measures such as device infection control, replacement of potentially polluted plasmapheresis fluids, disinfecting the environment and replacing old sterile washing water with new sources were carried out in plasmapheresis unit. In conclusion, R. pickettii is a rare nosocomial infection that is responsible for the contamination of medical equipment, especially in hemodialysis, plasmapheresis devices and sterile solutions. Also, it is suggested that the role and importance of rare environmental bacteria as the causative agents of human infections should not be ignored in medical centers.

A case of Guillain-Barré syndrome related to COVID-19 infection

BACKGROUND

After the first COVID-19 case, reported neurological complications are increasing day by day.

METHOD

In this paper, we present a benign-course Guillain-Barré syndrome (GBS) emerging 2 weeks after COVID-19 infection in a 35-years-old male.

RESULTS

Cough and fever were started 18 days ago and his PCR test was resulted positive for COVID-19 infection. After treatment and quarantine were completed, he developed sudden leg weakness following autonomic features. Cerebrospinal fluid was suggestive for GBS despite the electrodiagnostic test was not helpful because it was done in the first days. He recovered without needing any immunotherapy.

CONCLUSION

Our case suggested that COVID-19 can cause atypical benign GBS forms in addition to well-known variants. Comprehensive studies are needed to describe the unknowns and determine the exact prevalence of GBS after COVID-19 infection, including mild cases that did not require hospital admission.

Progressive quadriparesis and inflammation: A common disease, a rare presentation

A previously healthy, 10-years-old girl presented with progressively worsening pain and weakness of the limbs for the past 2 weeks. It initially started with low-grade fever lasting for 4 days followed by severe pain over bilateral lower and upper limbs. Gradually she became bed-ridden. On examination, she had severe neck rigidity, generalized tenderness all over the body, generalized hyperalgesia, hyporeflexia, bilateral extensor plantar response and toe-walking. An initial clinical diagnosis of Landry-Guillain Barry syndrome was considered. Nerve conduction study showed generalized, demyelinating polyneuropathy. She was administered IVIG and was evaluated for other causes of arachnoiditis. MRI brain and spine showed enhancement and clumping of nerve roots in the conus and cauda equina. CECT chest showed necrotic mediastinal lymphnodes. A final diagnosis of disseminated tuberculosis with tuberculous arachnoiditis was considered and she was administered ATT, pulse methylprednisolone followed by maintenance oral corticosteroids. Currently, after 5 months of therapy, she has recovered clinically.

[Classification of pregnancy complicating Guillain-Barré syndrome]

Objective: To explore the classification, clinical features, the short-term efficacy of intravenous immunoglobulin (IVIg) for Guillain-Barré syndrome(GBS) and look for predictors of acute motor axonal neuropathy (AMAN) during pregnancy. Methods: The clinical data of 45 hospitalized pregnant patients with GBS recruited from October 2008 to October 2017 at the Tianjin Medical University general hospital, Handan City First Hospital and Nankai University Affiliated Tianjin Fourth Central Hospital, were collected and analyzed retrospectively, and patients were divided into the acute inflammatory demyelinating polyneuropathies (AIDP) group and the AMAN group. The clinical features and efficacy of IVIg were compared between the two groups. Logistic regression analysis was used to analyze the predictors of AMAN. Results: There were 25 cases in the AIDP group and 20 cases in the AMAN group. AIDP usually started with distal limb weakness (P=0.001), and AMAN often started with limb weakness (P=0.001) and mostly accompanied by dyspnea (P=0.042). AIDP was often associated with paresthesia (P=0.001) and autonomic dysfunction (P=0.007). The response days of active treatment in the AIDP group and the AMAN group were (1.6±0.5)d and (2.3±0.8)d (P=0.022), the improvement days were (3.6±0.8)d and (5.9±1.0)d (P=0.000), the basic cure days were (7.7±1.3)d and (9.0±0.8)d (P=0.002), the cure days were (12.3±1.1)d and (12.8±0.9)d (P=0.148). Multivariate Logistic regression analysis revealed that preceding diarrhea (OR=13.750; 95% CI 1.386-136.387), limb weakness(OR=12.000;95% CI 2.359-61.048) and limb weakness with dyspnea (OR=10.000; 95% CI 1.048-95.457) were significantly associated with the AMAN-type GBS. Conclusions: AIDP and AMAN are the main types of pregnancy complicating GBS. Most patients present with a single and benign course of disease. IVIg is generally safe and effective. Preceding diarrhea, limb weakness and limb weakness with dyspnea are the predictors of AMAN-type pregnancy complicating GBS.

Ayurveda management of Guillain-Barre syndrome: A case report

Guillain-Barre syndrome (GBS) is a severe acute paralytic neuropathy with rapid progression usually occurring post infections. Inspite of the active medications it is associated with severe weakness, incomplete recovery and pain. Long disease course can cause autonomic dysfunction or deterioration in general health and life threatening complications like respiratory failures. Current case was diagnosed as GBS with motor, sensory & sphincter disturbance. Ayurveda diagnosis of Sarvangavata was made and customized treatment strategy was planned. First part of Kapha pitta samrushtavata (Vatadosha associated with Kapha and Pitta dosha) and then vatahara chikitsa were followed. Treatments were Koshta shodhana (gut cleansing), Abhyanga (massage of whole body with medicated oil), Ksheera parisheka (dripping of medicated milk over body), Shastikashali panda sweda (Rubbing of medicated rice poultice over body), Anna lepa (application of medicated rice over the body), Shirotalam (trans cranial drug administration by applying medicines over scalp), Basti (trans rectal administration of medicines) and Oral medicaments. Panchakarma treatments were for 14 days followed by oral medications for next 151 days. Intervention period of 165 days showed complete recovery of all the motor, sensory & sphincter deficits however follow up of the patient was maintained for 437 days looking in to the sustainability of the outcomes.

Zika virus infection as a cause of congenital brain abnormalities and Guillain-Barré syndrome: From systematic review to living systematic review

Background. The Zika virus (ZIKV) outbreak in the Americas has caused international concern due to neurological sequelae linked to the infection, such as microcephaly and Guillain-Barré syndrome (GBS). The World Health Organization stated that there is “sufficient evidence to conclude that Zika virus is a cause of congenital abnormalities and is a trigger of GBS”. This conclusion was based on a systematic review of the evidence published until 30.05.2016. Since then, the body of evidence has grown substantially, leading to this update of that systematic review with new evidence published from 30.05.2016 – 18.01.2017, update 1.

Methods. We review evidence on the causal link between ZIKV infection and adverse congenital outcomes and the causal link between ZIKV infection and GBS or immune-mediated thrombocytopaenia purpura. We also describe the transition of the review into a living systematic review, a review that is continually updated.

Results. Between 30.05.2016 and 18.01.2017, we identified 2413 publications, of which 101 publications were included. The evidence added in this update confirms the conclusion of a causal association between ZIKV and adverse congenital outcomes. New findings expand the evidence base in the dimensions of biological plausibility, strength of association, animal experiments and specificity. For GBS, the body of evidence has grown during the search period for update 1, but only for dimensions that were already populated in the previous version. There is still a limited understanding of the biological pathways that potentially cause the occurrence of autoimmune disease following ZIKV infection.

Conclusions. This systematic review confirms previous conclusions that ZIKV is a cause of congenital abnormalities, including microcephaly, and is a trigger of GBS. The transition to living systematic review techniques and methodology provides a proof of concept for the use of these methods to synthesise evidence about an emerging pathogen such as ZIKV.

Influenza a infection unmasking an underlying mitral valve stenosis in a 19-year-old boy

Infection with Influenza virus is uncommon in the present times, though a number of cases were reported during pandemics in 1918 in various regions of America. We report a case where a young male patient presented to the hospital with a clinical picture of acute respiratory distress syndrome that turned out to be a viral pneumonia caused by Influenza A virus and it aggravated an underlying yet undiagnosed mitral valve stenosis.