Epidemiological, clinical, and electrodiagnostic findings in childhood Guillain-Barré syndrome: a reappraisal

Variation in worldwide incidence of Guillain-Barré syndrome: a population-based study in urban China and existing global evidence

Background and objectives

Geographical variation existed in the incidences of Guillain-Barré syndrome (GBS), but no national population-based study has evaluated the incidences of GBS in China. This study aimed to estimate the incidence of GBS in urban China and evaluate the worldwide variation in the incidence of GBS.

Methods

Firstly, we did a population-based study to calculate the incidence of GBS in urban China based on the National Urban Medical Insurance database from 2013 to 2017. To identify GBS cases, natural language processing was used first for handling the lengthy and unstructured diagnostic information and then checked by prestigious neurologists. Secondly, a systematic review and meta-analysis were performed to analyze the incidence of GBS worldwide. Up to July 4, 2022, Medline, Embase, and Web of Science were retrieved to identify the population-based studies regarding the incidence of GBS. The basic information and the statistics regarding incidence were extracted. Quality assessment considered sample representativeness, condition assessment, and statistical methods.

Results

A total of 1.44 billion person-years in insurance data was covered, with 3,534 GBS cases identified. The annual incidences of GBS in urban China between 2013 and 2017 ranged from 0.41 (95% CI: 0.27 to 0.58) to 0.58 (95% CI: 0.38 to 0.82) per 100,000 person-years. The incidence was the highest in Northwest China and the lowest in Northeast China. The meta-analysis included 122 articles. The quality assessment showed that the quality scores of 43.3% of studies were ≥ 0.75 (the total score is 1). The global incidence of GBS was 1.12 (95% CI: 0.98 to 1.27) per 100,000 person-years. The incidences in West Europe, South Asia, and North Europe were higher, while the incidences in Australia and New Zealand, Southeast Asia, and North Africa were lower. The incidence of enteric infections was positively associated with the incidence of GBS (coefficient=0.0000185, P=0.007). The incidence in Europe, Australia, and America rose significantly from 1960 to 2020 (coefficient=0.01, t=2.52, P=0.015).

Discussion

There is a clear regional variation of the GBS incidence at both national and global levels. Careful control of enteric infections should be conducted to reduce the disease burden.

[Guillain-Barre syndrome in children]

Guillain-Barré syndrome (GBS) is an immune-mediated disease of the peripheral nervous system that can occur in both children and adults. The classic presentation of GBS is characterized by progressive symmetrical, ascending muscle weakness. Patients with GBS require meticulous monitoring due to the risk of bulbar syndrome, respiratory failure and autonomic dysfunction, which can be life-threatening. Early diagnosis and timely prescription of pathogenetic therapy for GBS are particularly important, especially in young children. Meanwhile, the spectrum of disorders covered by GBS has expanded significantly; its eponym is now designate any variant of acute dysimmune polyneuropathy, and its atypical forms pose a serious diagnostic problem for clinicians. This review article provides an analysis of the data available in the medical literature on GBS in children and discusses the tactics for diagnosing and managing patients with GBS, taking into account the Russian and European clinical recommendations.

Assessment of neurological sequelae and new-onset symptoms in the long-term follow-up of paediatric Guillain-Barre syndrome: A longitudinal study from India

BACKGROUND

Guillain-Barre syndrome (GBS) is the commonest cause of acute flaccid paralysis in children. There is a paucity of studies that assess the long-term outcome of paediatric GBS.

AIM

To assess the frequency of neurological sequelae and the new-onset symptoms in the long-term follow-up of paediatric GBS and to identify the risk factors associated with them.

METHODS

This longitudinal study involved 78 children with GBS treated between January 2015 and 2021. The parents of those children were contacted to visit the hospital for a detailed neurological examination and to look for new-onset symptoms after the initial treatment for GBS.

RESULTS

Of the 78 children, acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy, and acute motor-sensory axonal neuropathy variants were observed in 30 (38.5%), 27 (34.6%) and 11 (14.1%) children, respectively. The median (interquartile range (IQR)) duration of follow-up was 3 (2, 4.5) years. The median (IQR) time to independent ambulation was 30 (13.5, 105) days. The neurological sequelae were found in 22 (28.2%) children. GBS disability score at admission (odds ratio (OR) = 4.6; 95% confidence interval (CI): 1.1-19.8; P = 0.04) and axonal variant of GBS (OR = 4.1; 95% CI: 1.5-20.8; P = 0.04) were found to be independent predictors of neurologic sequelae. A total of 28 children experienced new-onset symptoms after GBS, with frequent falls while running and fatigue being the predominant symptoms. Those children with demyelinating variant achieved independent ambulation earlier than the axonal group on survival analysis (log-rank P value = 0.04).

CONCLUSION

The presence of neurological sequelae and new-onset symptoms were found in 28.2 and 35% of the GBS children, respectively. High GBS disability score at admission and axonal variant of GBS were independent predictors of neurological sequelae. Knowledge about these would help in devising a plan for rehabilitation.

Intravenous immunoglobulin therapy for HIV-associated Guillain-Barré syndrome

OBJECTIVE

To compare the efficacy of intravenous immunoglobulin (IVIG) added to antiretroviral therapy (ART) and ART alone in people living with human immunodeficiency virus-associated Guillain-Barré syndrome (HIV-associated GBS).

METHODS

The study was a retrospective analysis of clinical records of HIV-associated GBS patients from department of neurology at West China Hospital between January 2015 and October 2020. Patients treated with ART alone were compared with those treated with IVIG + ART. The primary outcome was the GBS disability score at 4 weeks, which was assessed with multivariable ordinal regression. Additional outcomes include the GBS disability scale at 1 week, improvement of ≥ 1 point on the GBS disability score at 1 and 4 weeks, median change in the MRC sum score at 1 and 4 weeks, number of patients who were able to walk independently at 4 weeks.

RESULTS

Two hundred and fifty-two (252) individuals living with HIV were recruited in the study. According to the inclusion and exclusion criteria, 21 HIV-associated GBS patients were finally included, of whom 8 were treated with IVIG + ART and 13 were treated with ART alone. At the fourth weeks after treatment, the GBS disability scale grade was significantly lower in patients treated with IVIG + ART than those with ART alone (1 vs. 2, P = 0.02). The adjusted OR for a lower GBS disability scale was 10.6 (95 % CI 1.15 to 98.05; P = 0.03) for the IVIG + ART group. Moreover, 6 of 8 (75 %) patients treated with IVIG + ART were able to walk independently at four weeks after treatment.

CONCLUSIONS

The introduction of IVIG combined with ART may be efficacious in the treatment of HIV-infected GBS and may provide better clinical outcomes.

Prognostic value of contrast-enhanced MRI in Guillain-Barré syndrome in children

BACKGROUND

The aim of this retrospective study is to explore the prognostic value of different contrast enhancement imaging patterns in childhood Guillain-Barré syndrome by comparing the clinical, laboratory, and therapeutic outcomes.

METHODS

We included a total of 37 patients who were diagnosed and followed up by a pediatric neurology team at Montpellier University Hospital between 2000 and 2016. All images were reinterpreted by the first author and a senior pediatric neuroradiology staff member in two different sessions; in the case of disagreement, the expert's reading was considered.

RESULTS

The study group comprised 22 (59.5%) boys and 15 (40.5%) girls. The age ranged from 1.5 year to 14.8 years. Muscle weakness was present in 33 (89.2%) patients. Cranial nerves involvement was observed in 22 (59.5%) patients, while 29 (78.4%) patients had albuminocytological dissociation. In 27 (73%) patients, contrast enhancement or thickening of the lumbosacral nerve roots was found. Simultaneous spinal nerve root and cranial nerve enhancement was noted in five (17.2%) patients, while isolated cranial nerve enhancement was identified in three (10.3%) patients. Clinical and radiological cranial nerve involvement was found in seven (18.9%) patients, while isolated clinical cranial nerves involvement occurred in 13 (35.1%) patients. No significant correlation between different magnetic resonance imaging (MRI) enhancement patterns and short-term or long-term outcomes was found in our cohort.

CONCLUSION

Contrast-enhanced brain and spinal MRI is a sensitive and recommended supportive test for diagnosing acute inflammatory polyradiculopathy in children. Its predictive value for clinical, and therapeutic outcomes in the short or long term has not yet been proved.

Prognostic model for time to achieve independent walking in children with Guillain-Barré syndrome

BACKGROUND

Guillain-Barré Syndrome (GBS) is an immune-mediated peripheral neuropathy. Clinical features and outcomes in children differ from adults. Currently, there is no prognostic model to predict outcomes in children and existing models for adults are not suitable.

OBJECTIVES

To identify factors that are associated with outcomes and develop clinical model to predict time to independent walking in children with GBS.

METHODS

Between 2005 and 2018, 41 patients with GBS were identified by retrospective chart review. Factors associated with independent walking were analyzed with the Kaplan-Meier method. A prediction model was developed based on regression coefficients from Cox's proportional hazard model.

RESULTS

The disability score at maximum weakness and nerve conduction study results were associated with independent walking and included in the model. Scores range from 0 to 5. A score of 5 predicts 34 days to independent walking while a score of 0 predicts 5 months (mean 158 days, p = 0.008).

CONCLUSION

This scoring system for pediatric patients provides predicts the time needed to achieve independent walking, an important milestone of recovery for communication with parents, and to assist clinicians to optimize treatment. Further studies of predictive factors and external validation are needed to improve precision of the model.

IMPACT

This is the first study to create a prognostic scoring system for individual outcomes in children with GBS. A clinical prognostic model can predict time to achieve independent walking in individual pediatric patients with GBS. This model can assist clinicians to optimize treatment and guide decisions on rehabilitation to prevent long-term disability.

Therapeutic plasma exchange as a first-choice therapy for axonal Guillain-Barré syndrome: A case-based review of the literature (Review)

Guillain-Barré syndrome is an acute immune-mediated disease that affects the peripheral nervous system, with progressive motor deficit in the limbs, sometimes involvement of the cranial nerves and possible impairment of the autonomic nervous system. Due to the respiratory and autonomic nervous dysfunction, the disease has the potential to be fatal. Although modern methods of treatment have significantly improved patient prognosis, many patients nevertheless experience significant neurological sequelae. The practical applicability of plasmapheresis was illustrated in our case report. We report the case of a 27-year-old man who had a mild viral respiratory tract infection 1 week prior to the onset of disease with gradual development of a motor deficit, urinary retention, slight swallowing difficulties and mild respiratory dysfunction. Nerve conduction studies were performed and the diagnosis of acute motor axonal neuropathy phenotypic variant of Guillain-Barré syndrome was established. Autoimmune and inflammatory diseases, infectious diseases, endocrinopathies, neoplastic diseases, intoxications, metabolic diseases and vitamin deficiencies were ruled out. Our patient attended four sessions of therapeutic plasma exchange performed using peripheral venous approach with two needles with significant recovery of the motor deficit. The patient was discharged 1 week later on maintenance kinetotherapy with further favorable evolution. In conclusion, we report a good evolution as a result of therapeutic plasma exchange in a patient with acute motor axonal neuropathy phenotypic variant of Guillain-Barré syndrome. The procedure is well-tolerated and can be performed safely by peripheral approach not only in the intensive care unit but also in a neurology clinic.

Severe Locked-In-Like Guillain-Barré's Syndrome: Dilemmas in Diagnosis and Treatment

Guillain-Barré's syndrome in childhood can follow an atypical course, increasing the challenges in diagnosis and decisions regarding immunomodulatory treatment. Here, we report the case of on a 13-year-old boy with acute onset Guillain-Barré's syndrome progressing over 40 days to a very severe, locked-in-like syndrome despite intensive immunomodulatory treatment. After a plateau phase lasting 3 months and characterized by fluctuating signs of ongoing inflammatory disease activity, we were prompted to perform repeated and maintenance immunomodulatory treatment, which resulted in a continuous and nearly complete recovery of function. Atypical features at disease onset, the severe "total" loss of all peripheral and cranial nerve function, and an apparent late response to treatment give rise to reviewing the dilemmas of diagnosis and treatment in such severe and protracted courses of Guillain-Barré syndrome.

Clinical Outcome of Guillain-Barré Syndrome in 108 Children

Objectives

To review the clinical outcome and electrophysiologic characteristics of children with Guillain-Barré syndrome (GBS) from Eastern India.

Methods

The hospital records of the children aged less than 12 years with a final diagnosis of GBS at our hospital from November, 2015 to December, 2018 were reviewed. Disabilities were assessed at 8-weeks and 6-month follow-up using Hughes scale (0–6).

Results

Demyelinating variety in 57 patients (52.8%) was more common than the axonal variety (33.3%). 71.1% (32/45) of GBS patients had recovered (scale 0,1) during the follow up period of 6 months. These included 67.7% (21/31) of the axonal variety and 78.6% (11/14) of the demyelinating variety.

Conclusion

Irrespective of the severity, disability is less with the demyelinating variety as compared with the axonal subtype.

Electrophysiological subtypes and associated prognosis factors of Mexican adults diagnosed with Guillain-Barré syndrome, a single center experience

BACKGROUND

The clinical characteristics of electrophysiological subtypes and prognostic factors of Mexican adults diagnosed with Guillain-Barré Syndrome (GBS) have not been described.

MATERIALS AND METHODS

A single center, ambispective, cohort study was performed (2015-2019). GBS was defined following the Asbury and Cornblath criteria. Electrodiagnosis was made according to Hadden criteria. Clinical, biochemical and electrodiagnostic parameters were described, compared and analyzed using a multivariate model. Only patients who completed a 3-month follow-up were included.

RESULTS

137 GBS patients (92 males; mean age 46.6 ± 16.6).132 (96.3%) underwent an electrodiagnostic assessment.68 (51.5%) were classified as axonal GBS, with further classified into two groups: acute motor axonal neuropathy (AMAN) 45.4%, and acute motor and sensory axonal neuropathy (AMSAN) 8,6%. The following characteristics were lower in the AMAN group: Medical Research Counsel sumscore (MRC) 30.1 ± 16.3 vs 36.4 ± 14.4, unilateral facial palsy 10% vs 25.9% and albuminocytologic dissociation 41.3% vs. 71.7%.Multivariate analysis found AMAN as an independent predictor of an unfavorable outcome OR: 3.34 (p = 0.03) CONCLUSIONS: AMAN subtype is the most frequent presentation of GBS in Mexican adult patients and an independent predictor of inability to walk independently at 3 months after discharge.

Clinical Characteristics and Electrodiagnostic Features of Guillain-Barré Syndrome Among the Pediatric Population

INTRODUCTION

Guillain-Barré syndrome is an immune-mediated peripheral neuropathy characterized by different clinical manifestations. We aimed to describe the clinical features, seasonal distribution, subtypes, and electrodiagnostic characteristics of Iranian children with Guillain-Barré syndrome.

METHODS

In this prospective study, a total of 30 children with Guillain-Barré syndrome were evaluated. All demographic features were collected and electrodiagnostic study was assessed.

RESULTS

Twelve participants were diagnosed with acute inflammatory demyelinating polyradiculoneuropathy and 18 patients were identified with acute motor axonal neuropathy. The initial findings showed that a significant number of patients (23 cases, P = .003) resided in rural areas. Our results showed a higher incidence of Guillain-Barré syndrome in summer and autumn months. No significant difference was observed between the seasonal distribution of acute inflammatory demyelinating polyradiculoneuropathy and acute motor axonal neuropathy subtypes. Antecedent history of pulmonary infections was recorded in 14 children with Guillain-Barré syndrome. Electrophysiological findings revealed a pattern of prolonged F wave latency with reduced persistency, absence of sensory nerve action potential, reduced compound muscle action potential amplitude, prolonged distal motor latency, reduced nerve conduction velocity, and abnormal temporal dispersion or conduction block in most patients with acute inflammatory demyelinating polyradiculoneuropathy. However, reduced compound muscle action potential amplitude, F wave with normal latency and reduced persistency, normal sensory nerve action potential amplitude, normal distal latency, normal sensory nerve conduction velocity, and conduction block or temporal dispersion were observed in most acute motor axonal neuropathy patients.

CONCLUSION

The data support a correlation between Guillain-Barré syndrome incidence with seasonal variation and living area. Further studies should assess the Guillain-Barré syndrome features in pediatric population.

Guillain-Barré syndrome in children: subtypes and outcome

OBJECTIVE

This study reviews the clinical features, subtypes, and outcomes of childhood Guillain-Barré syndrome (GBS).

METHODS

Fifty-four children who attended a tertiary care training and research hospital in Turkey were enrolled in the study.

RESULTS

The mean age was 6.5 ± 4.2 years and 32 patients (59.5%) were male. The most common subtype of GBS was acute inflammatory demyelinating polyneuropathy (AIDP), which was seen in 27 patients (50%). Having antecedent history, especially upper respiratory tract infection was significantly more common in AIDP (P = 0.028). Sensorial symptoms were significantly more frequent in axonal type GBS (P = 0.001). When we compare the demyelinating and axonal forms, all of the groups had favorable outcome.

CONCLUSION

The diagnosis of pediatric GBS can be delayed because of its variable presentation. Early admission to hospital and early treatment are important for decreasing the need for respiratory support and improving the outcome.

Guillain-Barré syndrome in Colombia: where do we stand now?

Guillain-Barré syndrome (GBS) is a rapid-onset muscle weakness disease caused by the immune-mediated damage of the peripheral nervous system. Since there is an increase incidence of GBS cases in Latin America, particularly in Colombia, and most of them are currently preceded by Zika virus (ZIKV) infection, we aimed to assess the available evidence of the disease in Colombia through a systematic literature review. Out of 51 screened abstracts, only 16 corresponded to articles that met inclusion criteria, of which 15 were case reports or case series. A total of 796 cases of GBS were reported in the included articles. The majority of patients were males (66.8 %) and younger than 50 years old (94 %). An infectious disease before the onset of GBS was registered in 31 % of patients, with gastrointestinal or respiratory symptoms being the most frequently observed. In those cases in which electrodiagnostic tests were performed, the most common subphenotype was acute inflammatory demyelinating polyneuropathy (17 %). Death was reported in 15 % of patients. Data regarding GBS in Colombia is scant and heterogeneous. Taking into account the burden of the disease and the recent rise of GBS cases associated with ZIKV, a careful patient evaluation and a systematic collection of data are warranted. A form to data gathering is proposed.

Quantification of Campylobacter jejuni contamination on chicken carcasses in France

Highly prevalent in poultry, Campylobacter is a foodborne pathogen which remains the primary cause of enteritis in humans. Several studies have determined prevalence and contamination level of this pathogen throughout the food chain. However it is generally performed in a deterministic way without considering heterogeneity of contamination level. The purpose of this study was to quantify, using probabilistic tools, the contamination level of Campylobacter spp. on chicken carcasses after air-chilling step in several slaughterhouses in France. From a dataset (530 data) containing censored data (concentration <10CFU/g), several factors were considered, including the month of sampling, the farming method (standard vs certified) and the sampling area (neck vs leg). All probabilistic analyses were performed in R using fitdistrplus, mc2d and nada packages. The uncertainty (i.e. error) generated by the presence of censored data was small (ca 1 log₁₀) in comparison to the variability (i.e. heterogeneity) of contamination level (3 log₁₀ or more), strengthening the probabilistic analysis and facilitating result interpretation. The sampling period and sampling area (neck/leg) had a significant effect on Campylobacter contamination level. More precisely, two "seasons" were distinguished: one from January to May, another one from June to December. During the June-to-December season, the mean Campylobacter concentration was estimated to 2.6 [2.4; 2.8] log₁₀ (CFU/g) and 1.8 [1.5; 2.0] log₁₀ (CFU/g) for neck and leg, respectively. The probability of having >1000CFU/g (higher limit of European microbial criterion) was estimated to 35.3% and 12.6%, for neck and leg, respectively. In contrast, during January-to-May season, the mean contamination level was estimated to 1.0 [0.6; 1.3] log₁₀ (CFU/g) and 0.6 [0.3; 0.9] log₁₀ (CFU/g) for neck and leg, respectively. The probability of having >1000CFU/g was estimated to 13.5% and 2.0% for neck and leg, respectively. An accurate quantification of contamination level enables industrials to better adapt their processing and hygiene practices. These results will also help in refining exposure assessment models.

Acute axonal neuropathy subtype of Guillain Barré syndrome in a French pediatric series: Adequate follow-up may require repetitive electrophysiological studies

Different subtypes of Guillain Barré Syndromes (GBSs) are defined by their electrophysiological characteristics, acute inflammatory demyelinating neuropathy (AIDP), and acute motor/motor-sensory axonal forms (AMAN/AMSAN) with either reversible nerve conduction failure (RCF) or axonal degeneration. Our aim was to describe initial clinical and electrophysiological characteristics of axonal forms of GBS in a pediatric population and their short- and long-term evolution. Electroneuromyogram (ENMG) results were collected at diagnosis and at two months of evolution and interpreted using the recently proposed pattern of RCF vs axonal degeneration. Clinical evaluation was standardized using the GBS disability scale ("GBSds") at diagnosis, and then at 3, 6, and 12 months of evolution. Outcome was compared to those of patients with AIDP diagnosed within the same period. Eleven patients were included, among whom eight patients presenting with AMAN and three with AMSAN. Two subgroups were identified according to severity. Three patients had a severe form (GBSds ≥2 at 12 months), two of them presenting an axonal degeneration on ENMG studies. Seven patients had a less severe form (GBSds ≤1 at 12 months), five of them with RCF on ENMG studies. Axonal forms had a more severe evolution than demyelinating forms (n = 17) at 3 months (median GBSds 3 and 2, respectively), 6 months (2 and 0), and 12 months (1 and 0), (p < 0,05). Axonal forms of GBS in children have a more severe global outcome than demyelinating forms. Axonal degeneration in two successive early ENMGs may be a prognostic factor of poor outcome.

Increased rates of Guillain-Barré syndrome associated with Zika virus outbreak in the Salvador metropolitan area, Brazil

In mid-2015, Salvador, Brazil, reported an outbreak of Guillain-Barré syndrome (GBS), coinciding with the introduction and spread of Zika virus (ZIKV). We found that GBS incidence during April–July 2015 among those ≥12 years of age was 5.6 cases/100,000 population/year and increased markedly with increasing age to 14.7 among those ≥60 years of age. We conducted interviews with 41 case-patients and 85 neighborhood controls and found no differences in demographics or exposures prior to GBS-symptom onset. A higher proportion of case-patients (83%) compared to controls (21%) reported an antecedent illness (OR 18.1, CI 6.9–47.5), most commonly characterized by rash, headache, fever, and myalgias, within a median of 8 days prior to GBS onset. Our investigation confirmed an outbreak of GBS, particularly in older adults, that was strongly associated with Zika-like illness and geo-temporally associated with ZIKV transmission, suggesting that ZIKV may result in severe neurologic complications.

Shortly following the introduction of Zika virus (ZIKV), a type of flavivirus transmitted by mosquitoes, into Brazil in early 2015, the Brazil Ministry of Health began receiving increased reports of a paralyzing condition known as Guillain-Barré syndrome (GBS). The areas with the greatest number of GBS cases appeared to correlate geographically and temporally with the areas reporting the highest rate of ZIKV infections. This association had been previously observed during a ZIKV outbreak in French Polynesia, however, this had not been systematically examined in a case-control investigation for the ZIKV outbreak in South America. In this investigation, the authors found that the occurrence of GBS in the affected population was nearly four times higher than would be expected, and the risk for GBS was particularly elevated among older adults. GBS was associated with ZIKV-like symptoms and with a combination of ZIKV-like symptoms plus laboratory evidence of a recent flavivirus infection. Taken together, these findings provide strong support for and greater understanding of the link between ZIKV and GBS.

Disturbance of Plasma Lipid Metabolic Profile in Guillain-Barre Syndrome

Guillain-Barre Syndrome (GBS) is an inflammatory disease of the peripheral nervous system. Given that plasma metabolic profiles in GBS patients have never been explored, plasma samples of 38 GBS patients, 22 multiple sclerosis (MS) patients, and 40 healthy controls were analyzed by using untargeted and targeted metabolomics analysis. The untargeted analysis showed that levels of a set of plasma lipid metabolites were significantly decreased in GBS patients compared to the controls. Furthermore, the targeted analysis demonstrated that levels of 41 metabolites in GBS patients were significantly changed compared to either the controls or MS patients. A further metabolic analysis showed that 12 of 41 metabolites were significantly lower in classical GBS patients compared to Miller-Fisher syndrome. Among them, each of PCae C34:0, PCae C42:2, PCae C42:3, and SM C24:0 was inversely correlated with Hughes functional grading scale of GBS patients at both nadir and discharge. Receiver operating characteristic curve analysis of combination of three metabolites (PCaa C42:2, PCae C36:0 and SM C24:0) showed a good discrimination between the GBS and the controls (area under curve = 0.86). This study has demonstrated disruption of lipid metabolites in GBS may be potential biomarkers to indicate disease severity and prognosis of GBS.

Predictive factors for achieving independent walking in children with Guillain-Barre syndrome

BackgroundTo determine the predictors of achieving independent walking at 2 and 6 months after onset of weakness in children with Guillain-Barre syndrome (GBS).MethodsChildren with GBS admitted to the Tabriz Children's Hospital were studied prospectively. All patients had frequent clinical evaluations until achieving independent walking. Unaided walking at 2 and 6 months and factors influencing these outcomes were determined using both univariate and multiple analyses.ResultsBetween 2003 and 2014, 324 children (mean age: 5.3±3.66 years) were admitted. The mean duration to independent walking was 2.97±3.02 months; 90.5% of patients could walk independently at 6 months. In the univariate analysis, disability score of >3 (P=0.03), autonomic nerve involvement (P=0.003), cranial nerve involvement (P=0.008), and absent compound muscle action potential (CMAP; P=0.048) were found to be significantly associated with poor walking outcome at 6 months. In the multivariate analysis, cranial nerve involvement (P=0.008) and absence of CMAP (P=0.022) were independently associated with poor functional outcome.ConclusionDisability score >3, cranial and autonomic nerve involvement, and absence of CMAP were predictors of independent walking in childhood GBS in this study; early rehabilitation program may prevent further impairments secondary to immobility in these patients.

Age may contribute to the increased frequency of axonal Guillain-Barré syndrome

INTRODUCTION

The frequency of axonal Guillain-Barré syndrome (GBS) varies among countries. Previous studies supporting the high frequency of axonal GBS in South America have been carried out with pediatric populations. We seek to determine the frequency of axonal GBS in both children and adults in South America.

METHODS

This is a retrospective cohort analysis of patients who were diagnosed with GBS between January 2006 and December 2013 in a neurological center in Buenos Aires, Argentina. Adults and children with a diagnosis of GBS were included and classified by applying Ho and colleagues' criteria¹ for axonal GBS.

RESULTS

The study included 105 patients with GBS. Among 58 adults, only 5 individuals were classified as axonal GBS compared with 16 of 47 children. The frequency of axonal GBS was significantly higher in children than in adults (34% vs. 8.6%, P = 0.0001).

DISCUSSION

As shown in a cohort of South American patients, age may impact the frequency of axonal GBS. Muscle Nerve 56: 1311-1313, 2017.

Anti-ganglioside antibodies in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy in Chinese patients

INTRODUCTION

In this study we investigated the relationships between anti-ganglioside antibodies and Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP).

METHODS

Samples from 48 Chinese patients diagnosed with GBS and 18 patients diagnosed with CIDP were retrospectively reviewed.

RESULTS

In the GBS patients, 62.5% were classified as having acute inflammatory demyelinating polyneuropathy (AIDP), 27.1% were found to have acute motor axonal neuropathy (AMAN), and 10.4% were unclassified. Serum IgG anti-ganglioside antibodies were detected in 46.2% of the AMAN patients and in 6.7% of the AIDP patients (P < 0.05); 5.6% of the 18 CIDP patients were IgG antibody positive, and 27.8% were IgM antibody positive. Facial palsy and sensory impairment were significantly associated with IgM antibodies.

CONCLUSIONS

These results suggest that IgG anti-GM1 antibodies are associated with AMAN, but not with AIDP, and that IgM antibodies against GM1, GM2, and GM3 are associated with facial nerve palsy. Muscle Nerve 55: 470-475, 2017.

Acute Ataxia in Children: A Review of the Differential Diagnosis and Evaluation in the Emergency Department

Acute ataxia in a pediatric patient poses a diagnostic dilemma for any physician. While the most common etiologies are benign, occasional individuals require urgent intervention. Children with stroke, toxic ingestion, infection, and neuro-inflammatory disorders frequently exhibit ataxia as an essential-if not the only-presenting feature. The available retrospective research utilize inconsistent definitions of acute ataxia, precluding the ability to pool data from these studies. No prospective data exist that report on patients presenting to the emergency department with ataxia. This review examines the reported causes of ataxia and attempts to group them into distinct categories: post-infectious and inflammatory central and peripheral phenomena, toxic ingestion, neurovascular, infectious and miscellaneous. From there, we synthesize the existing literature to understand which aspects of the history, physical exam, and ancillary testing might aid in narrowing the differential diagnosis. MRI is superior to CT in detecting inflammatory or vascular insults in the posterior fossa, though CT may be necessary in emergent situations. Lumbar puncture may be deferred until after admission in most instances, with suspicion for meningitis being the major exception. There is insufficient evidence to guide laboratory evaluation of serum, testing should be ordered based on clinical judgement-recommended studies include metabolic profiles and screening labs for metabolic disorders (lactate and ammonia). All patients should be reflexively screened for toxic ingestions.

Distinct Clinical Characteristics of Pediatric Guillain-Barré Syndrome: A Comparative Study between Children and Adults in Northeast China

Objective

Clinical characteristics of pediatric Guillain-Barré syndrome (GBS) have been extensively studied whereas scarcely been compared with those of adult GBS. Herein we compared the clinical features of GBS between pediatric and adult patients.

Methods

We retrospectively collected the clinical data of 750 patients with GBS (541 adults and 209 children), and compared the clinical characteristics between children and adults.

Results

Pain was a more frequent complaint in children (17.2% vs 9.6%, p < 0.01), who were also found with shorter interval from disease onset to nadir (6.3d vs 7.3d, p < 0.01) and higher incidence of bulbar dysfunction (22.0% vs 14.8%, p < 0.05). The disease severity in children was comparable with adults. In addition, a higher incidence of pediatric GBS was found in summer, especially in July and August (both p < 0.01). However, the incidence of antecedent infections of different seasons in adult and pediatric patients was comparable (p > 0.05). The clinical features of acute motor axonal neuropathy (AMAN) and acute inflammatory demyelinating polyneuropathy (AIDP) in children were overall comparable with adult ones (p > 0.05). Similar to adults, bulbar dysfunction (odds ratio [OR]: 4.621, 95% confidence interval [CI]: 1.240–17.218, p < 0.05) and lower nadir Medical Research Council (MRC) sum score (OR: 0.897, 95% CI: 0.855–0.941, p < 0.01) were also risk factors for mechanical ventilation in children. However, distinct from adult ones, autonomic dysfunction was significantly higher in mechanically ventilated childhood GBS (39.1% vs 8.8%, p < 0.01), which also served as a predictor for mechanical ventilation in pediatric GBS (OR: 70.415, 95% CI: 9.265–535.158, p < 0.01). As to the efficacy of intravenous immunoglobulin, insignificant difference was identified between children and adults.

Conclusion

The clinical features of pediatric GBS differ from those of adults. Autonomic dysfunction is an independent risk factor for mechanical ventilation in pediatric patients.

Pediatric Guillain-Barré syndrome: Indicators for a severe course

Objectives:

This study aims to retrospectively evaluate pediatric Guillain-Barré syndrome cases in a tertiary center in Istanbul, Turkey.

Materials and Methods:

The data of 40 patients with Guillain-Barré syndrome who had been admitted to the Department of Pediatrics at the Istanbul University Medical Faculty between 2005 and 2011 were collected. Mann-Whitney U, Kruskal-Wallis, chi-square, and Fisher's exact tests were used for statistical analysis.

Results:

Mean patient age was 5.4 ± 3.0 years; 20 out of 40 patients (50%) were female and 20 (50%) were male. Preceding infection was detected in 32 cases (80%). Six patients had speech impairment. Out of eight patients with respiratory distress (20%), five required respiratory support (12.5%) of which three of them had speech impairment as well. According to nerve conduction studies, 21 patients (52.5%) had acute inflammatory demyelinating polyradiculoneuropathy, 14 (35%) had acute motor axonal neuropathy, and five (12.5%) had acute motor-sensory axonal neuropathy. Thirty-three patients (82.5%) received intravenous immunglobulin, 3 (7.5%) underwent plasmapheresis and 4 (10%) received both. Time until recovery (P = 0.022) and time until aided (P = 0.036) and unaided (P = 0.027) walking were longer in patients with acute gastrointestinal infection than in those with upper respiratory tract infection (P < 0.05). Time until response to treatment (P = 0.001), time until aided (P = 0.001) and unaided (P = 0.002) walking, and time until complete recovery (P = 0.002) were longer in acute motor axonal neuropathy cases as compared to acute inflammatory demyelinating polyradiculoneuropathy cases.

Conclusion:

Recovery was longer with acute gastrointestinal infection and acute motor axonal neuropathy. Speech impairment could be a clinical clue for the need of mechanical ventilation.

A multicentre prospective study of Guillain-Barré syndrome in Japan: a focus on the incidence of subtypes

OBJECTIVE

Guillain-Barré Syndrome (GBS) is classified into the two major subtypes; acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor axonal neuropathy (AMAN). Previous studies have suggested that AIDP is predominant and AMAN is rare in Western countries, whereas AMAN is not always uncommon in East Asia. We aimed to clarify the incidence of the subtypes of GBS in Japan.

METHODS

We performed a prospective multicentre survey over 3 years (2007-2010). Clinical and electrophysiological findings were collected from 184 patients with GBS in 23 tertiary neurology institutes. Anti-ganglioside antibodies were measured by ELISA. We also surveyed the incidence of Fisher syndrome (FS).

RESULTS

By electrodiagnostic criteria of Ho et al, patients were classified as having AIDP (40%), or AMAN (22%), or unclassified (38%). Anti-GM1 IgG antibodies were found for 47% of AMAN patients, and 18% of AIDP patients (p<0.001). There were no specific regional trends of the electrodiagnosis and anti-GM1 positivity. During the same study period, 79 patients with FS were identified; the percentage of FS cases out of all cases (FS/(GBS+FS)) was 26%.

CONCLUSIONS

The frequency of GBS patients with the electrodiagnosis of AMAN by single nerve conduction studies is approximately 20% in Japan, and the AMAN pattern is closely associated with anti-GM1 antibodies. The incidence of FS appears to be much higher in Japan than in Western countries.

Guillain-Barré syndrome: subtypes and predictors of outcome from India

There is a paucity of large studies evaluating the subtypes of Guillain-Barré syndrome (GBS) and their outcome from Southeast Asia. We report cliniconeurophysiological subtypes of GBS and their correlation with triggering events and 3-month outcome from northern India. Three hundred and twenty eight consecutive patients with GBS were clinically evaluated, including their triggers, severity, autonomic involvement, cranial nerve palsy, and respiratory paralysis. Nerve conduction study (NCS) was repeated at 3 weeks if the initial study was normal. They were categorized into acute inflammatory demyelinating polyradiculoneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor sensory axonal neuropathy (AMSAN), inexcitable motor nerve, and equivocal. Clinically, 204 (62.2%) patients had pure motor, 106 (32.3%) motor sensory, 16 (4.9%) Miller Fisher syndrome, and 2 (0.6%) pure sensory GBS. Based on NCS, 242 (73.8%) had AIDP, 44 (13.4%) AMAN, 15 (4.6%) AMSAN, 8 (2.4%) inexcitable motor nerves, and 27 (8.2%) equivocal GBS. AIDP patients were older, more common in summer, had lesser peak disability, and better outcome compared to those with AMAN. Eleven (3.4%) patients died and 48 (14.6%) had poor outcome at 3 months. The poor outcome was related to severity, dysautonomia, and inexcitable motor nerves. AIDP is the commonest variant of GBS in our study and has better outcome compared to AMAN.

Guillain-Barré syndrome in Asia

Over the past 20 years, the most notable advance in understanding Guillain-Barré syndrome (GBS) has been the identification of an axonal variant. This advance arose chiefly through studies undertaken in East Asian countries and comprised two major aspects: first, the immunopathogenesis of axonal GBS related to anti-ganglioside antibodies and molecular mimicry of Campylobacter jejuni; and second, the observation that distinct electrophysiological patterns of axonal GBS existed, reflecting reversible conduction failure (RCF). As a consequence, the pathophysiology of acute motor axonal neuropathy (AMAN) has perhaps become better understood than acute inflammatory demyelinating polyneuropathy. Despite these more recent advances, a critical issue remains largely unresolved: whether axonal GBS is more common in Asia than in Europe or North America. If it is more common in Asia, then causative factors must be more critically considered, including geographical differences, issues of genetic susceptibility, the role of antecedent infections and other potential triggering factors. It has become apparent that the optimal diagnosis of AMAN requires serial electrophysiological testing, to better delineate RCF, combined with assessment for the presence of anti-ganglioside antibodies. Recent collaborative approaches between Europe and Asia have suggested that both the electrophysiological pattern of AMAN and the seropositivity for anti-ganglioside antibodies develop similarly. Separately, however, current electrodiagnostic criteria for AMAN limited to a single assessment appear inadequate to identify the majority of cases. As such, diagnostic criteria will need to be revised to improve the diagnostic sensitivity for AMAN.

Acute polyradiculoneuritis: Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is an acute, immune-mediated, postinfectious polyneuropathy with symmetrical ascending weakness, diminished deep tendon reflexes, and nonspecific sensory symptoms. CSF protein is raised with normal or only slightly elevated cell count. Based on electrophysiological and pathological findings, a demyelinating variant (acute inflammatory demyelinating polyneuropathy, AIDP) and an axonal variant (acute motor axonal neuropathy, AMAN) can be differentiated. Molecular mimicry with common epitopes between infective agents and peripheral nerves is discussed as an important pathophysiological principle. The symptoms progress for a mean of 10 days (up to 4 weeks) and after a plateau of 1-2 weeks remit spontaneously. At the height of the disease 60% of children are unable to walk and 10-15% need artificial ventilation. Treatment with plasmapheresis and intravenous immunoglobulins (IVIG) has been proven in placebo-controlled studies in adults with severe disease to speed up recovery significantly. In children, mostly open studies have shown similar treatment effects, although their spontaneous course is frequently less severe. Children with GBS should be treated with IVIG when they have lost the ability to walk, or when they are still deteriorating significantly and are expected to lose the ability to walk. The long-term prognosis is more favorable than that in adults. Whereas 25% of patients maintain mild neurological symptoms and signs, disability in the long term is very rare and usually due to complications such as myelitic involvement or chronic inflammatory demyelinating polyneuropathy (CIDP).

Axonal Guillain-Barré syndrome: concepts and controversies

Acute motor axonal neuropathy (AMAN) is a pure motor axonal subtype of Guillain-Barré syndrome (GBS) that was identified in the late 1990s. In Asia and Central and South America, it is the major subtype of GBS, seen in 30-65% of patients. AMAN progresses more rapidly and has an earlier peak than demyelinating GBS; tendon reflexes are relatively preserved or even exaggerated, and autonomic dysfunction is rare. One of the main causes is molecular mimicry of human gangliosides by Campylobacter jejuni lipo-oligosaccharides. In addition to axonal degeneration, electrophysiology shows rapidly reversible nerve conduction blockade or slowing, presumably due to pathological changes at the nodes or paranodes. Autoantibodies that bind to GM1 or GD1a gangliosides at the nodes of Ranvier activate complement and disrupt sodium-channel clusters and axoglial junctions, which leads to nerve conduction failure and muscle weakness. Improved understanding of the disease mechanism and pathophysiology might lead to new treatment options and improve the outlook for patients with AMAN.

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.

Weakness and the inability to ambulate in a 14-month-old female: a case report and concise review of guillain-barre syndrome

Guillain-Barre syndrome (GBS) is an acquired disease of the peripheral nervous system which causes demyelination and leads to weakness, ataxia, and areflexia. There are a variety of forms of the syndrome, and although it is found in all age groups, it is rare in children less than two years of age. The present complaint of weakness, ataxia, or lower extremity pain in the pediatric population should cause the practitioner to consider GBS in the differential. We describe a case of a 14-month-old girl presenting with weakness and the inability to ambulate who was diagnosed with GBS. The purpose of this paper is to review the emergency medicine diagnosis and management of Guillain-Barre syndrome in children.

Clinical features and prognosis with Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute inflammatory polyneuropathy commonly characterized by rapidly progressive, symmetric weakness and areflexia.

MATERIALS AND METHODS

We retrospectively assessed the clinical manifestations, results of electrodiagnostic tests, functional status and prognosis of 36 children diagnosed with GBS.

RESULTS

Based on clinical and electrophysiological findings, the patients were classified as having acute inflammatory demyelinating polyradiculoneuropathy (AIDP) (n = 25), acute motor axonal neuropathy (AMAN) (n = 10) and acute motor-sensory axonal neuropathy (AMSAN) (n = 1). Twenty (55.5%) patients were males and 16 (44.5%) patients were females. The mean age of the 36 patients was 68.1 ± 45.01 months (range, 6-180 months). Five (13.8%) patients were younger than 2 years. The most common initial symptoms were limb weakness, which was documented in 34 (94.4%) patients. In our study, 18 patients (51.4%) showed albuminocytological dissociation (raised protein concentration without pleocytosis) on cerebrospinal fluid (CSF) examination. Three patients (8.3%) required mechanical ventilation therapy during hospitalization. Unfortunately, three (8.3%) patients died; one patient had AIDP and two patients had axonal involvement (one case was AMAN and another case was AMSAN). When we compared the cases of residual sequel/dead and cases of complete recovery for neural involvement type including AIDP, AMAN and AMSAN, we did not find a statistically significant difference between the groups (P > 0.05).

CONCLUSION

Our findings showed that cases of GBS was not uncommon in children younger than 2 years of age, and CSF protein level might be found high in the first week of the disease in about one half of the patients, with a higher rate of morbidity and mortality in patients with axonal involvement than in those with AIDP.

Approach to a child with acute flaccid paralysis

Acute flaccid paralysis (AFP) is a clinical syndrome characterized by rapid onset weakness, that many times includes respiratory and bulbar weakness. AFP is a broad clinical entity with an array of diagnostic possibilities. An accurate and early diagnosis of the cause has important bearing on the management and prognosis. The immediate priorities in a child who presents with acute progressive weakness are; to detect and manage respiratory muscle weakness, to detect and manage bulbar weakness, evaluate for cardiovascular instability, detect and manage dyselectrolytemia or toxemia, and to detect and manage a spinal compression (traumatic, intraspinal collections). Urgent imaging of the spine is needed in settings where a spinal cord involvement is suspected. Compressive or traumatic spinal lesions may need early neurosurgical intervention. Anterior horn cell injury is usually due to direct viral infection. More distal pathologies are generally immune mediated and respond to immunomodulation. Irrespective of the cause, generalized weakness frequently affects respiratory and bulbar function. Such children need careful monitoring and respiratory support.

Clinical characteristics of Guillain-Barré syndrome in a tropical country: a Brazilian experience

OBJECTIVE

To analyze the clinical variants, outcomes, and prognosis of Guillain-Barré syndrome (GBS) in a Brazilian population.

MATERIALS AND METHODS

Clinical and laboratory data of 149 cases of GBS diagnosed from 1994 to 2007 were analyzed.

RESULTS

Acute inflammatory demyelinating polyneuropathy (AIDP) was the most frequent variant (81.8%) of GBS, followed by acute motor axonal neuropathy (AMAN) (14.7%) and acute motor and sensory axonal neuropathy (AMSAN) (3.3%). The incidence of GBS was 0.3/100,000 for the state of Rio Grande do Norte and cases occurred at a younger age. GBS was preceded by infections, with the axonal variant associated with episodes of diarrheas (P = 0.025). Proximal weakness was more frequent in AIDP, and distal weakness predominant in the axonal variant. Compared to 42.4% of cases with AIDP (P < 0.0001), 84.6% of cases with the axonal variant had nadir in <10 days. Individuals with the axonal variant took longer to recover deambulation (P < 0.0001). The mortality of GBS was 5.3%.

CONCLUSION

A predominance of the AIDP variant was seen, and the incidence of the disease decreased with age. As expected, the distribution of weakness correlated with the clinical variants, and individuals with the axonal variant had a poorer prognosis.

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.

Outcome in childhood Guillain-Barré syndrome

OBJECTIVE

To prospectively assess the outcome of children diagnosed with Guillain-Barré syndrome (GBS), followed up for a median duration of 25 months.

METHODS

Tertiary center, prospective follow up of children with GBS enrolled between, Dec 2003 to Sep 2006. Functional recovery was determined at 12 months and later using Hughes scale (0-6). Clinical, electrophysiological variables were compared between the good outcome (grade 0/1) and bad outcome groups (died or functional grade >1).

RESULTS

Among 52 children with a median age of five yr there was male preponderance (75.4%). Mortality during acute phase was 11.5% (6/52). Among the survivors long term data was obtainable in 40 of the 46 children. At one year follow up 87.5% children had fully recovered or had minimal symptoms, beyond one year this rose to 95%. Only 2 among 40 had significant symptoms at last follow up (1 grade-2 and 1 grade-3). Factors significantly associated with poor outcome were: need for artificial ventilation, inexitable nerves on nerve conduction testing and delayed independent walking.

CONCLUSION

Children needing ventilation have the worst short-term prognosis. However, irrespective of severity during acute phase, good long-term recovery can be expected in most children.

Motor recovery after Guillain-Barré syndrome in childhood

PURPOSE

To determine the clinical factors that modify the recovery time for gait after Guillain-Barré syndrome (GBS) in childhood.

METHOD

Medical records of patients admitted to Instituto de Ortopedia Infantil Roosevelt (IOIR) between years 1991 and 2001, were reviewed. Age, sex, cranial nerve impairment, requirement of assisted ventilation, number of days of assisted ventilation, muscular strength at day 10 of the disease, presence of quadriplegia, intravenous infusion of human gamma globulins (IVIG), were taken as independent variables. The number of needed days to reach Hughes State III was taken as the major outcome. First, univariate analysis was performed and with the factors that showed a statistically significant association with recovery time, multiple linear regression analysis and Cox regression were also performed.

RESULTS

Data of 332 children under 15 years old was collected. (Mean age: 7.1 years). A sample of 215 children was gathered for the study, all of them were regarded as functional states IV or V. Acute Motor Axonal Neuropathy (AMAN) was found in 30% of all cases. In the univariate analysis Cranial nerve impairment, requirement of assisted ventilation, presence of quadriplegia and presence of non-excitable motor nerves were associated with delayed motor recovery time. Patients who received IVIG reached Hughes state III faster than those who received only support treatment. This finding, that was more important in the presence of Acute Inflammatory Demyelinating Polyradiculoneuropathy (AIDP), lost its value in the Cox regression analysis. In the multivariate analysis, muscular strength, assessed at day 10 of the disease was the most important predictor to determine motor recovery. The presence of quadriplegia was strongly associated with a delayed recovery time. Relative risk: 3.3 (95% Confidence Interval 2.1 - 5.2).

CONCLUSIONS

Muscular strength at day 10 of the disease is the most useful clinical factor to determine prognosis of motor recovery in children who have suffered Guillain-Barré syndrome.

Childhood acute and chronic immune-mediated polyradiculoneuropathies

Immune-mediated polyradiculoneuropathies are divided into Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). In children subacute inflammatory demyelinating polyradiculoneuropathy is included in CIDP. Immune polyradiculoneuropathies are not exclusively demyelinating, and axonal forms also responding favourably to immunotherapy occur. Evidence-based data on efficacy of therapy in children is lacking, relying on retrospective data, open label studies on small numbers of children, and mainly adult derived data. Immunotherapy (intravenous human immunoglobulin [IVIg] and plasmapheresis) shortens GBS recovery time with most children recovering completely. Childhood CIDP usually responds to corticosteroids and slow tapering is required to prevent relapses. IVIg and plasmapheresis are also effective. CIDP children resistant to steroids, IVIg, and steroid-dependent patients present a therapeutic challenge. Immunosuppressive agents including methotrexate, azathioprine and cyclosporine are helpful in some cases. Anecdotal reports of treatment with interferons alpha or beta and monoclonal antibodies against specific B-cell antigens (Rituximab, Alemtuzumab) have been described in limited case reports. Childhood CIDP prognosis is mostly favourable. However, a proportion of cases have residual neurological deficit.

Decreased intrathecal synthesis of prostaglandin D2 synthase in the cerebrospinal fluid of patients with acute inflammatory demyelinating polyneuropathy

Prostaglandin D(2) synthase (PGDS) is the most abundant brain protein in cerebrospinal fluid (CSF) and is tied closely with inflammatory processes. This study investigated whether CSF PGDS levels in patients with acute inflammatory demyelinating polyneuropathy (AIDP) are altered. The results suggest that PGDS concentration is significantly increased in the CSF of AIDP patients compared with the control patients (p<0.05) due to a blood-CSF barrier dysfunction, whereas the intrathecal synthesis of PGDS, reflected by the CSF PGDS/albumin ratio, is significantly decreased in AIDP compared with the control group (p<0.05). The changes of CSF PGDS/albumin ratio are only observed in AIDP patients, but not in Miller Fisher Syndrome (MFS), chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), or multiple sclerosis (MS) patients.

Clinical presentation and prognosis of childhood Guillain-Barré syndrome

AIM

Guillain-Barré syndrome (GBS) is an acute inflammatory polyneuropathy commonly characterised by rapidly progressive, symmetric weakness and areflexia. This study is to assess the clinical characteristics of paediatric GBS, as well as its long-term functional prognosis.

METHODS

We retrospectively assessed the clinical manifestations, results of electrodiagnostic tests, functional status and prognosis of 56 children diagnosed with GBS. Based on clinical and electrophysiological findings, the patients were classified as having acute inflammatory demyelinating polyradiculoneuropathy ([AIDP]n = 34), acute motor axonal neuropathy ([AMAN]n = 14), acute motor and sensory axonal neuropathy (n = 1) and Miller Fisher syndrome ([MFS]n = 7).

RESULTS

Upper respiratory infection was the most frequent preceding event, and limb weakness was the most frequent symptom at GBS onset. There was no significant difference in the mean time from the onset of illness to nadir between any of these groups. Both the AIDP and AMAN groups showed significantly poorer functional status, measured by the Hughes scale, than the MFS group. Two years after nadir, however, the three groups did not differ significantly. Functional status at nadir, as estimated by the Hughes scale, is a more important factor than electrophysiological types in predicting long-term outcome.

CONCLUSION

The most common symptom at onset in paediatric GBS was limb weakness. Functional status at nadir in AMAN was not significantly different from that of AIDP, and both types achieved good functional outcome for ambulation after 2 years. Functional status at nadir was more important than the electrophysiological type in predicting long-term outcomes.

An Atypical Case of Neuralgic Amyotrophy with Respiratory Muscle Weakness: Case Report and Review of Literature

This report is of an atypical case of neuralgic amyotrophy with a Horner's syndrome, bilateral brachial plexus, lumbar plexus and phrenic nerve involvement. The diagnosis is confirmed based on a classical history and examination findings with typical neurophysiological investigations for this condition. This report also highlights the novel use of positional magnetic resonance imaging to investigate patients with respiratory muscle weakness. This case report expands the recognised clinical features of neuralgic amyotrophy and the literature concerning atypical features of this condition is reviewed.

Status epilepticus secondary to hypertensive encephalopathy as the presenting manifestation of Guillain-Barré syndrome

Malignant hypertension due to autonomic dysfunction is a known complication of Guillain-Barré syndrome. We describe a child who presented with status epilepticus secondary to hypertensive encephalopathy who, in recovery, was found to be areflexic. Nerve conduction studies confirmed the clinical diagnosis of Guillain-Barré syndrome. She was treated with antihypertensive and antiseizure medications and intravenous immune globulin with complete resolution of her autonomic symptoms and improvement in her weakness. Guillain-Barré syndrome may result in hypertensive encephalopathy that can manifest as status epilepticus before the onset of motor symptoms.

IVIG therapy in neurological disorders of childhood

There is growing evidence that intravenous immunoglobulins (IVIG) are effective in some neuroimmunological disorders of childhood. This short review summarizes the evidence-based indications and recommendations of IVIG therapy in these disorders. Despite considerable efforts to define the role and mechanisms of IVIG, more clinical studies are needed to further explore the therapeutic potential of IVIG in childhood diseases of the nervous system and muscle.