Acute "axonal" Guillain-Barré syndrome in childhood

[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.

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.

Clinical and subclinical autonomic dysfunction in chronic inflammatory demyelinating polyradiculoneuropathy

Autonomic neuropathy, although common in Guillain-Barré syndrome, is considered rare in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and has not been systematically investigated in that disorder. The present study was aimed at determining the prevalence of autonomic dysfunction and investigating the integrity of autonomic nervous system (ANS) reflexes in CIDP. We studied 17 patients with idiopathic CIDP and 20 healthy controls. Six quantitative autonomic function tests (AFTs) were used: Valsalva ratio, 30/15 ratio, and inspiration-expiration difference for parasympathetic function; and tilt test, handgrip test, and sympathetic skin response for sympathetic function. Eleven patients had symptoms of autonomic dysfunction. AFTs were abnormal in 13 patients. Parasympathetic and sympathetic systems were affected with equal frequency. The tilt test was abnormal most frequently, followed by the 30/15 ratio. Three patients developed postural hypotension with loss of consciousness during the tilt test. Abnormality of AFTs did not correlate with the presence of dysautonomic symptoms; duration, severity, and clinical course of the disease; or with age or gender of patients. Our study suggests a higher frequency of clinical and subclinical involvement of the ANS in CIDP than previously estimated. Dysautonomic symptoms are frequent but are mild. However, upon prolonged passive standing, autonomic failure can lead to loss of consciousness. The subclinical involvement of the ANS affects mainly the sympathetic vasomotor and parasympathetic cardiovascular fibers.

Childhood Guillain-Barré syndrome: clinical and electrophysiologic features predictive of outcome

The hospital records of 27 children with the diagnosis of Guillain-Barré syndrome were retrospectively reviewed. Based on the time to recovery, patients were divided into two groups: group 1 consisted of children whose times to complete or partial recovery extended beyond 2 months from onset of the disease; group 2 consisted of children who attained a full recovery within 2 months from onset of the disease. The clinical and electrophysiologic features of the two groups were statistically compared for their predictive value of outcome. Three clinical features (maximum disability score at presentation, intubation, and cranial nerve involvement) were predictive of poor outcome, whereas one electrophysiologic feature (conduction block) was predictive of favorable outcome. There was also a significant correlation between maximum disability score at presentation and the probability of intubation.

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

We evaluated 61 children with Guillain-Barré syndrome, 14 months to 14 years of age, admitted to the Hospital Nacional de Pediatria in Buenos Aires. According to the electrodiagnostic findings, they fit into two groups, those with acute motor axonal neuropathy (AMAN) (18 patients) and those with acute inflammatory demyelinating polyradiculoneuropathy (AIDP) (43 patients). Ninety percent of the children with AMAN resided in suburban or rural areas without running water, whereas half of the AIDP patients lived in a metropolitan district. Summer and winter months showed a higher incidence of both variants. Children with AMAN were younger, evolved more acutely, reached a higher maximum disability score, required assisted ventilation more often, had lower mean level of cerebrospinal fluid protein, improved more slowly, and had a poorer outcome 6 months and 12 months after onset. Electrophysiological findings in those with AIDP revealed a pattern of severe diffuse slowing in children 5 years old or younger and a multifocal pattern in children 6 years old or older. This difference was not reflected in the clinical picture. In contrast, AMAN showed a uniform pattern with normal sensory conduction, severely reduced compound muscle action potential amplitude, near normal conduction velocity, and early denervation. Epidemiological, clinical, electrodiagnostic, cerebrospinal fluid, and prognostic data indicate that these variants of Guillain-Barré syndrome should be regarded as different entities.

Intravenous immunoglobulin in very severe childhood Guillain-Barré syndrome

To evaluate intravenous immunoglobulin (IVIG) therapy in children with very severe Guilain-Barré syndrome (GBS) with reference to the need for respiratory support, ICU stay and long-term outcome, we studied 33 children with very severe GBS and quadriparesis and/or respiratory muscle weakness admitted to the Pediatric Intensive Care Unit (PICU) of PGIMER, Chandigarh. Cases (n = 22, IVIG group) were enrolled prospectively, and controls (n = 11), similar to cases in age and severity of illness, retrospectively. All children received similar supportive and respiratory care. In addition, cases were given IVIG (Sandoglobulin, Sandoz) 0.4 g/kg bodyweight per day for 5 days. The mean age, duration of symptoms prior to admission and severity of illness in the two groups were similar. In the IVIG group, onset of recovery of muscle power was significantly earlier (day 14.8 (6.8) of illness vs day 20.9 (8.6), p < 0.05) and the length of PICU stay significantly shorter (20.5 (13.0) days vs 50.5 (33.3) days, p < 0.01). Sixteen (72.7%) children in the IVIG group had improved by at least one functional grade after 1 month and 15 (68%) were walking independently after 3 months compared with two (18%) and four (36%) controls, respectively (p < 0.05). The number of children who needed endotracheal intubation and mechanical ventilation and the duration of mechanical ventilation was significantly less in the IVIG-treated group. We conclude that in very severe GBS in children IVIG therapy improves outcome to a remarkable extent, reduces the need for intubation and mechanical ventilation, shortens the length of stay in ICU, and promotes ambulation sooner.

An epidemiologic, clinical, and therapeutic study of childhood Guillain-Barré syndrome in Kuwait: is it related to the oral polio vaccine?

We studied Guillain-Barré syndrome, affecting children 12 years old or less, throughout Kuwait, in the period between January 1, 1992, and March 31, 1997. Nineteen children had the diagnostic criteria of Guillain-Barré syndrome, with an overall annual incidence rate of 0.95/100,000 population at risk. Female patients outnumbered male patients with a sex ratio of 1.4:1. There was a clustering of cases in winter and spring and in the year 1996. The disease symptoms were relatively severe in our patients because only 16% (3 of 19) of them were able to walk at the height of their illness, whereas the rest were bed or chair bound or needed assisted ventilation. Two patients had the electrodiagnostic features of axonal neuropathy and both had residual deficits on follow-up, whereas the rest recovered fully. All the patients received intravenous immunoglobulin. The mean time to walk unaided was 23.5 days (range, 2-84 days) after intravenous immunoglobulin and excluding the two patients with axonal neuropathy, and full recovery was achieved in a mean time of 103 days (range, 30-300 days). Contrary to previous studies, we found no correlation between oral polio vaccine administration and Guillain-Barré syndrome in 2 successive years (1995 and 1996) during a nationwide campaign targeting children less than 5 years old.

Fulminant demyelinating neuropathy mimicking cerebral death

Guillain-Barré syndrome can very rarely present with acute quadripares and cranial nerve involvement resembling a locked-in state. We describe a very unusual case of fulminant neuropathy in a child who was previously exposed to vincristine. The clinical picture resembled brain death; however, electrodiagnostic studies led to the diagnosis of a peripheral neuropathy. Serial electrodiagnostic studies and pathologic findings confirmed demyelination.

Intravenous immunoglobulin treatment in children with Guillain-Barré syndrome

We have retrospectively reviewed the data of 75 consecutive children diagnosed with Guillain-Barré syndrome (GBS) and hospitalized in two centres. There were 51 children with GBS treated in Ankara, Turkey and 24 patients treated in Toronto, Canada. To evaluate the effect of intravenous immunoglobulin (IVIG) treatment, the patients were divided into three groups. All 24 Canadian patients received IVIG in a dose of 1 g/kg/day for 2 days. In the Ankara group 23 children received 0.4 g/kg/day for 5 days and the remaining 28 patients in that group received supportive treatment only. In all but two patients IVIG was started within the first 2 weeks of neuropathic symptoms. The patients' data, including mean functional grades, frequency of bulbar signs and autonomic dysfunction and age were similar in all three groups. Analysis of the short-term outcome demonstrated that the patients treated with IVIG had a significantly faster rate of recovery. Mean time-lapse until improvement of one functional grade was 17.4 days in the IVIG group from Toronto, and 20.8 days in the IVIG group and 62.4 days in the non-IVIG group of patients from Ankara. We conclude that IVIG has considerable efficacy in the treatment of children with GBS. Furthermore, we have also demonstrated a faster rate of recovery in patients who received a total dose of IVIG in 2 days as opposed to 5 days.

Severe Guillain-Barré syndrome in childhood treated with human immune globulin

Thirteen children with severe Guillain-Barré syndrome were treated with human immune globulin. Patients received a mean total dose of 1.9 gm/kg of human immune globulin for 2 or 5 days. To evaluate the relationship between the response to human immune globulin and electrodiagnostic findings, we compared the clinical outcome of 3 groups of children. The first group consisted of 9 children with electrophysiologic evidence of a mean amplitude of the compound motor action potentials larger than 10% of the lower limit of normal. The second group of 4 children had inexcitable motor nerves. Children in the second group required longer periods to improve one functional grade (mean 67.3 days vs 18.8 days) and to reach grade 2 (219 days vs 32.7 days). Moreover, children in the second group were more disabled after 3 and 6 months, and they all remained with distal atrophy and weakness after 7 months of follow-up. Furthermore, the outcome of children in the second group was no different from that of a historic control of 5 untreated children with severe Guillain-Barré syndrome and similar electrophysiologic findings. Human immune globulin treatment in children with severe Guillain-Barré syndrome is safe, easy to administer, and does not increase the number of relapses. Nevertheless, it does not seem to benefit children with low mean compound motor action potential amplitude.

Neuromuscular disease: rehabilitation and electrodiagnosis. 2. Nerve disease

The purpose of this section of the Self-Directed Physiatric Education Program Study Guide on rehabilitation in diseases affecting nerve and muscle is to assist practitioners and trainees in physical medicine and rehabilitation by providing an overview of the evaluation, treatment, and rehabilitative care of patients with inherited and acquired neuropathies. Both diffuse and focal processes are discussed. Current research is briefly reviewed, and the utility and limitations of electrodiagnostic studies are discussed.