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Bellanti R, Rinaldi S. Guillain-Barré syndrome: a comprehensive review. Eur J Neurol 2024; 31:e16365. [PMID: 38813755 PMCID: PMC11235944 DOI: 10.1111/ene.16365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/31/2024]
Abstract
Guillain-Barré syndrome (GBS) is a potentially devastating yet treatable disorder. A classically postinfectious, immune-mediated, monophasic polyradiculoneuropathy, it is the leading global cause of acquired neuromuscular paralysis. In most cases, the immunopathological process driving nerve injury is ill-defined. Diagnosis of GBS relies on clinical features, supported by laboratory findings and electrophysiology. Although previously divided into primary demyelinating or axonal variants, this dichotomy is increasingly challenged, and is not endorsed by the recent European Academy of Neurology (EAN)/Peripheral Nerve Society (PNS) guidelines. Intravenous immunoglobulin and plasma exchange remain the primary modalities of treatment, regardless of the electrophysiological subtype. Most patients recover, but approximately one-third require mechanical ventilation, and 5% die. Disease activity and treatment response are currently monitored through interval neurological examination and outcome measures, and the potential role of fluid biomarkers is under ongoing scrutiny. Novel potential therapies for GBS are being explored but none have yet modified clinical practice. This review provides a comprehensive update on the pathological and clinical aspects of GBS for clinicians and scientists.
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Affiliation(s)
- Roberto Bellanti
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
| | - Simon Rinaldi
- Nuffield Department of Clinical NeurosciencesUniversity of OxfordOxfordUK
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2
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van Doorn PA, Van den Bergh PYK, Hadden RDM, Avau B, Vankrunkelsven P, Attarian S, Blomkwist-Markens PH, Cornblath DR, Goedee HS, Harbo T, Jacobs BC, Kusunoki S, Lehmann HC, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Umapathi T, Topaloglu HA, Willison HJ. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome. Eur J Neurol 2023; 30:3646-3674. [PMID: 37814552 DOI: 10.1111/ene.16073] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 10/11/2023]
Abstract
Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy. Symptoms may vary greatly in presentation and severity. Besides weakness and sensory disturbances, patients may have cranial nerve involvement, respiratory insufficiency, autonomic dysfunction and pain. To develop an evidence-based guideline for the diagnosis and treatment of GBS, using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology a Task Force (TF) of the European Academy of Neurology (EAN) and the Peripheral Nerve Society (PNS) constructed 14 Population/Intervention/Comparison/Outcome questions (PICOs) covering diagnosis, treatment and prognosis of GBS, which guided the literature search. Data were extracted and summarised in GRADE Summaries of Findings (for treatment PICOs) or Evidence Tables (for diagnostic and prognostic PICOs). Statements were prepared according to GRADE Evidence-to-Decision (EtD) frameworks. For the six intervention PICOs, evidence-based recommendations are made. For other PICOs, good practice points (GPPs) are formulated. For diagnosis, the principal GPPs are: GBS is more likely if there is a history of recent diarrhoea or respiratory infection; CSF examination is valuable, particularly when the diagnosis is less certain; electrodiagnostic testing is advised to support the diagnosis; testing for anti-ganglioside antibodies is of limited clinical value in most patients with typical motor-sensory GBS, but anti-GQ1b antibody testing should be considered when Miller Fisher syndrome (MFS) is suspected; nodal-paranodal antibodies should be tested when autoimmune nodopathy is suspected; MRI or ultrasound imaging should be considered in atypical cases; and changing the diagnosis to acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) should be considered if progression continues after 8 weeks from onset, which occurs in around 5% of patients initially diagnosed with GBS. For treatment, the TF recommends intravenous immunoglobulin (IVIg) 0.4 g/kg for 5 days, in patients within 2 weeks (GPP also within 2-4 weeks) after onset of weakness if unable to walk unaided, or a course of plasma exchange (PE) 12-15 L in four to five exchanges over 1-2 weeks, in patients within 4 weeks after onset of weakness if unable to walk unaided. The TF recommends against a second IVIg course in GBS patients with a poor prognosis; recommends against using oral corticosteroids, and weakly recommends against using IV corticosteroids; does not recommend PE followed immediately by IVIg; weakly recommends gabapentinoids, tricyclic antidepressants or carbamazepine for treatment of pain; does not recommend a specific treatment for fatigue. To estimate the prognosis of individual patients, the TF advises using the modified Erasmus GBS outcome score (mEGOS) to assess outcome, and the modified Erasmus GBS Respiratory Insufficiency Score (mEGRIS) to assess the risk of requiring artificial ventilation. Based on the PICOs, available literature and additional discussions, we provide flow charts to assist making clinical decisions on diagnosis, treatment and the need for intensive care unit admission.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium
- CEBaP, Belgian Red Cross, Mechelen, Belgium
| | - Patrik Vankrunkelsven
- Department of Public Health and Primary Care KU Leuven, Cochrane Belgium, CEBAM, Leuven, Belgium
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - H Stephan Goedee
- Department of Neurology, University Medical Center Utrecht, Brain Center UMC Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Susumu Kusunoki
- Department of Neurology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Helmar C Lehmann
- Department of Neurology, Medical Faculty Köln, University Hospital Köln, Cologne, Germany
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Institute, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yusuf A Rajabally
- Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Hugh J Willison
- Glasgow Biomedical Research Centre, University of Glasgow, Glasgow, UK
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3
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van Doorn PA, Van den Bergh PYK, Hadden RDM, Avau B, Vankrunkelsven P, Attarian S, Blomkwist-Markens PH, Cornblath DR, Goedee HS, Harbo T, Jacobs BC, Kusunoki S, Lehmann HC, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Umapathi T, Topaloglu HA, Willison HJ. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome. J Peripher Nerv Syst 2023; 28:535-563. [PMID: 37814551 DOI: 10.1111/jns.12594] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 10/11/2023]
Abstract
Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy. Symptoms may vary greatly in presentation and severity. Besides weakness and sensory disturbances, patients may have cranial nerve involvement, respiratory insufficiency, autonomic dysfunction and pain. To develop an evidence-based guideline for the diagnosis and treatment of GBS, using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, a Task Force (TF) of the European Academy of Neurology (EAN) and the Peripheral Nerve Society (PNS) constructed 14 Population/Intervention/Comparison/Outcome questions (PICOs) covering diagnosis, treatment and prognosis of GBS, which guided the literature search. Data were extracted and summarised in GRADE Summaries of Findings (for treatment PICOs) or Evidence Tables (for diagnostic and prognostic PICOs). Statements were prepared according to GRADE Evidence-to-Decision (EtD) frameworks. For the six intervention PICOs, evidence-based recommendations are made. For other PICOs, good practice points (GPPs) are formulated. For diagnosis, the principal GPPs are: GBS is more likely if there is a history of recent diarrhoea or respiratory infection; CSF examination is valuable, particularly when the diagnosis is less certain; electrodiagnostic testing is advised to support the diagnosis; testing for anti-ganglioside antibodies is of limited clinical value in most patients with typical motor-sensory GBS, but anti-GQ1b antibody testing should be considered when Miller Fisher syndrome (MFS) is suspected; nodal-paranodal antibodies should be tested when autoimmune nodopathy is suspected; MRI or ultrasound imaging should be considered in atypical cases; and changing the diagnosis to acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) should be considered if progression continues after 8 weeks from onset, which occurs in around 5% of patients initially diagnosed with GBS. For treatment, the TF recommends intravenous immunoglobulin (IVIg) 0.4 g/kg for 5 days, in patients within 2 weeks (GPP also within 2-4 weeks) after onset of weakness if unable to walk unaided, or a course of plasma exchange (PE) 12-15 L in four to five exchanges over 1-2 weeks, in patients within 4 weeks after onset of weakness if unable to walk unaided. The TF recommends against a second IVIg course in GBS patients with a poor prognosis; recommends against using oral corticosteroids, and weakly recommends against using IV corticosteroids; does not recommend PE followed immediately by IVIg; weakly recommends gabapentinoids, tricyclic antidepressants or carbamazepine for treatment of pain; does not recommend a specific treatment for fatigue. To estimate the prognosis of individual patients, the TF advises using the modified Erasmus GBS outcome score (mEGOS) to assess outcome, and the modified Erasmus GBS Respiratory Insufficiency Score (mEGRIS) to assess the risk of requiring artificial ventilation. Based on the PICOs, available literature and additional discussions, we provide flow charts to assist making clinical decisions on diagnosis, treatment and the need for intensive care unit admission.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium
- CEBaP, Belgian Red Cross, Mechelen, Belgium
| | - Patrik Vankrunkelsven
- Department of Public Health and Primary Care KU Leuven, Cochrane Belgium, CEBAM, Leuven, Belgium
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - H Stephan Goedee
- Department of Neurology, University Medical Center Utrecht, Brain Center UMC Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Susumu Kusunoki
- Department of Neurology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Helmar C Lehmann
- Department of Neurology, Medical Faculty Köln, University Hospital Köln, Cologne, Germany
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Institute, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yusuf A Rajabally
- Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Hugh J Willison
- Glasgow Biomedical Research Centre, University of Glasgow, Glasgow, UK
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El-Abassi RN, Soliman M, Levy MH, England JD. Treatment and Management of Autoimmune Neuropathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Shang P, Feng J, Wu W, Zhang HL. Intensive Care and Treatment of Severe Guillain-Barré Syndrome. Front Pharmacol 2021; 12:608130. [PMID: 33995011 PMCID: PMC8113987 DOI: 10.3389/fphar.2021.608130] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute polyneuropathy mostly characterized by acute flaccid paralysis with or without sensory/autonomous nerve dysfunction. Current immuno therapies including intravenous immunoglobulin (IVIg), plasma exchange (PE), and newly developed biological drugs benefit patients by alleviating hyperreactive immune responses. Up to 30% of patients develop respiratory failure during hospitalization and require mechanical ventilation and intensive care. Immunotherapies, mechanical ventilation, supportive care, and complication management during the intensive care unit (ICU) stay are equally emphasized. The most important aspect of intensive care and treatment of severe GBS, that is, mechanical ventilation, has been extensively reviewed elsewhere. In contrast to immunotherapies, care and treatment of GBS in the ICU setting are largely empirical. In this review, we intend to stress the importance of intensive care and treatment, other than mechanical ventilation in patients with severe GBS. We summarize the up-to-date knowledge of pharmacological therapies and ICU management of patients with severe GBS. We aim to answer some key clinical questions related to the management of severe GBS patients including but not limited to: Is IVIg better than PE or vice versa? Whether combinations of immune therapies benefit more? How about the emerging therapies promising for GBS? When to perform tracheal intubation or tracheostomy? How to provide multidisciplinary supportive care for severe cases? How to avert life-threatening complications in severe cases?
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Affiliation(s)
- Pei Shang
- Department of Neurology, First Hospital of Jilin University, Changchun, China
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic College of Medicine and Science, Rochester, MN, United States
| | - Jiachun Feng
- Department of Neurology, First Hospital of Jilin University, Changchun, China
| | - Wei Wu
- Department of Neurosurgery, First Hospital of Jilin University, Changchun, China
| | - Hong-Liang Zhang
- Department of Life Sciences, National Natural Science Foundation of China, Beijing, China
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Demuth S, Felten R, Sordet C, Chatelus E, Chanson JB, Arnaud L. Rheumatic presentations of Guillain-Barré syndrome as a diagnostic challenge: A case series. Joint Bone Spine 2021; 88:105144. [PMID: 33515790 DOI: 10.1016/j.jbspin.2021.105144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Guillain-Barré syndrome (GBS) is an immune-mediated acute polyradiculoneuritis often in post-infectious context. It is a therapeutic emergency as early treatment may prevent disabilities. Pain in GBS has been described extensively, may precede neurological symptoms and bring the patient to rheumatology departments in the first place. OBJECTIVE To describe the clinical presentations and diagnosis of GBS cases referred to rheumatology departments. METHOD For this retrospective case-series, we screened patients of the rheumatology department (university hospitals of Strasbourg), whose hospitalization records were associated with the ICD-10 Code G61.0 (GBS) from 1993 to 2020. We included patients fulfilling the 1990 NINDS criteria and level one of the Brighton collaboration criteria. We measured the time from symptoms onset to admission and from admission to lumbar puncture as a marker of outpatient and inpatient diagnosis delay, respectively. RESULTS We describe 8 GBS cases. Six had nociceptive-like prodromal pain: back pain (n=3), peripheral arthralgia (n=1) or diffuse myalgia (n=3). The median time from symptoms onset to admission was 7days [range: 3-60] and the median time from admission to lumbar puncture was 2days [range: 0-8]. Two patients became severely tetraparetic, one requiring intubation. At last follow-up (median: 5.5years; range: 0.5-23years), 4 patients had recovered completely and 4 kept disabilities. CONCLUSIONS Rheumatic presentations of GBS are rare and diverse. Rheumatologists should be aware of this presentation because early diagnosis and treatment may prevent rapid motor worsening. Rapidly progressive symmetric weakness and areflexia appear as the best clinical diagnosis markers.
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Affiliation(s)
- Stanislas Demuth
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Renaud Felten
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Christelle Sordet
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Emmanuel Chatelus
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Jean-Baptiste Chanson
- Service de neurologie, Hôpitaux Universitaires de Strasbourg, 1, avenue Molière, 67000 Strasbourg, France
| | - Laurent Arnaud
- Service de rhumatologie, Centre National de Référence des Maladies Auto-Immunes (RESO), Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France.
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Longitudinal study of neuropathic pain in patients with Guillain-Barré syndrome. Ir J Med Sci 2020; 190:1137-1142. [PMID: 33057880 DOI: 10.1007/s11845-020-02395-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to analyze neuropathic pain (NeP) and its therapy in patients with Guillain-Barré syndrome (GBS) during a 6-month follow-up period. METHOD This longitudinal multicenter study included 69 newly diagnosed adult GBS patients. NeP diagnosis was based on the criteria of Finnerup and confirmed by the PainDETECT Questionnaire (PD-Q). Severity of GBS was assessed by GBS disability scale (GDS). Patients were assessed: on day 14 (D14), day 28 (D28), month 3 (M3), and month 6 (M6) from the disease onset. RESULTS At D14, pain was present in 85.5% of patients, while 26.4% had NeP. At M6, 72.5% of patients had pain, 20.0% of them NeP. In acute GBS, pain intensity was higher in patients with NeP compared to those with non-NeP (p < 0.01). Pain intensity in patients with NeP did not change during time, but it decreased in patients with non-NeP at M6 (p < 0.05). Around 20% of GBS patients were on specific NeP medication throughout the observed period. One quarter of patients with NeP were not on specific NeP drug in the acute phase. Up to one third of patients with NeP were on NeP medication but still had significant NeP. Pooled PD-Q score was in correlation with pooled GDS score (rho = + 0.43, p < 0.01). CONCLUSIONS NeP is a common and potentially severe symptom in GBS that may persist for months. It is important to recognize NeP, start specific treatment on time, in adequate doses, and for prolonged period of time.
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Berciano J. Axonal degeneration in Guillain-Barré syndrome: a reappraisal. J Neurol 2020; 268:3728-3743. [PMID: 32607643 DOI: 10.1007/s00415-020-10034-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 11/28/2022]
Abstract
The aim of this review was to analyse the pathophysiology of axonal degeneration in Guillain-Barré syndrome (GBS) with emphasis on early stages (≤ 10 days after onset). An overview of experimental autoimmune neuritis (EAN) models is provided. Originally GBS and acute inflammatory demyelinating polyneuropathy were equated, presence of axonal degeneration being attributed to a "bystander" effect. Afterwards, primary axonal GBS forms were reported, designated as acute motor axonal neuropathy/acute motor-sensory axonal neuropathy. Revision of the first pathological description of axonal GBS indicates the coexistence of active axonal degeneration and demyelination in spinal roots, and pure Wallerian-like degeneration in peripheral nerve trunks. Nerve conduction studies are essential for syndrome subtyping, though their sensitivity is scanty in early GBS. Serum markers of axonal degeneration include increased levels of neurofilament light chain and presence of anti-ganglioside reactivity. According to nerve ultrasonographic features and autopsy studies, ventral rami of spinal nerves are a hotspot in early GBS. In P2-induced EAN models, the initial pathogenic change is inflammatory oedema of spinal roots and sciatic nerve, which is followed by demyelination, and Wallerian-like degeneration in nerve trunks possessing epi-perineurium; a critical elevation of endoneurial fluid pressure is a pre-requisite for inducing ischemic axonal degeneration. Similar lesion topography may occur in GBS. The repairing role of adaxonal Schwann cytoplasm in axonal degeneration is analysed. A novel pathophysiological mechanism for nerve trunk pain in GBS, including pure motor forms, is provided. The potential therapeutic role of intravenous boluses of methylprednisolone for early severe GBS and intractable pain is argued.
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Affiliation(s)
- José Berciano
- Professor Emeritus of Neurology, Service of Neurology, University Hospital "Marqués de Valdecilla (IDIVAL)", "Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED)", University of Cantabria, Santander, Spain.
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9
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Ding X, Jiang H, Hu X, Ren H, Cai H. Guillain-Barré Syndrome and Low Back Pain: Two Cases and Literature Review. Open Med (Wars) 2018; 13:503-508. [PMID: 30426088 PMCID: PMC6227845 DOI: 10.1515/med-2018-0074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/10/2018] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To describe the clinical, electrophysiological, and lumbar magnetic resonance imaging (MRI) features of two cases of atypical Guillain-Barré syndrome (GBS). Methods We reported two GBS variant cases with initial and prominent symptoms of low back pain. We analysed their clinical, electrophysiological, and lumbar MRI features. Results Two patients with GBS reported low back pain as the initial and prominent symptom, which was not accompanied by limb weakness. The electrophysiological study showed abnormal F-waves in the common peroneal and tibial nerves, and acute polyradiculoneuropathy in the cauda equina. Examination of the cerebrospinal fluid (CSF) showed albuminocytologic dissociation. Serum was positive for GQ1b-IgM antibodies. Lumbar MRI showed gadolinium enhancement of the nerve roots and cauda equina. A standard regime of intravenous immunoglobulin markedly alleviated the low back pain. Conclusions Low back pain caused by GBS should be differentiated from other diseases. This initial or early prominent symptom may delay the diagnosis of GBS; therefore, it is important to conduct a detailed electrophysiological, CSF, and gadolinium-enhanced lumbar MRI analysis.
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Affiliation(s)
- Xianjun Ding
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, HangzhouChina
| | - Hong Jiang
- Department of Neuroelectrophysiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, HangzhouChina
| | - Xingyue Hu
- Department of Neurology, Brain Research Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, HangzhouChina
| | - Hong Ren
- Department of Radiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, HangzhouChina
| | - Huaying Cai
- Department of Neurology, Brain Research Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou 310016, HangzhouChina
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Yao S, Chen H, Zhang Q, Shi Z, Liu J, Lian Z, Feng H, Du Q, Xie J, Ge W, Zhou H. Pain during the acute phase of Guillain-Barré syndrome. Medicine (Baltimore) 2018; 97:e11595. [PMID: 30142753 PMCID: PMC6113041 DOI: 10.1097/md.0000000000011595] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
In this study, we tried to describe the characteristics of pain and explore the association between the incidence of pain and abnormal laboratory test results in patients during the acute phase of Guillain-Barré syndrome (GBS).This retrospective cohort study enrolled 252 patients with GBS who were in the acute phase of the disease. We collected data regarding the location and type of pain, the onset time, clinical variables and laboratory tests, including the levels of uric acid (UA), albumin, cerebrospinal fluid protein (CSFP), cerebrospinal fluid glucose (CSFG), fasting glucose upon admission, and blood creatinine. The pain descriptors were compared to the severity of disease and laboratory examination results.Around 34.5% of the patients reported pain during the acute phase of GBS. Pain was negatively correlated with the disease severity during the acute phase. In total, 29 of the 87 (33.3%) patients reported pain during the 2 weeks preceding the onset of weakness. The concentration of CSFP was positively associated with the incidence of pain, while the concentrations of UA and albumin were not correlated with the incidence of pain.We found that 33.3% of the GBS patients experienced pain within 2 weeks of onset, and the pain was positively associated with CSFP concentration but was not correlated with disease severity.
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Affiliation(s)
- Shaoli Yao
- Department of Neurology, West China Hospital, Sichuan University
| | - Hongxi Chen
- Department of Neurology, West China Hospital, Sichuan University
| | - Qin Zhang
- Department of Neurology, West China Hospital, Sichuan University
| | - Ziyan Shi
- Department of Neurology, West China Hospital, Sichuan University
| | - Ju Liu
- Department of Neurology, West China Hospital, Sichuan University
| | - Zhiyun Lian
- Department of Neurology, West China Hospital, Sichuan University
| | - Huiru Feng
- Department of Neurology, West China Hospital, Sichuan University
| | - Qin Du
- Department of Neurology, West China Hospital, Sichuan University
| | - Jinlu Xie
- Department of Neurology, West China Hospital, Sichuan University
| | - Weihong Ge
- Department of Internal Medicine, Hospital of Chengdu Office of People's Govermment of Tibetan Autonomous Region
| | - Hongyu Zhou
- Department of Neurology, West China Hospital, Sichuan University, China
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11
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Berciano J. Spinal nerve involvement in early Guillain-Barré syndrome: The Haymaker and Kernohan's legacy. J Neurol Sci 2017; 382:1-9. [PMID: 29110997 DOI: 10.1016/j.jns.2017.09.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 09/05/2017] [Accepted: 09/11/2017] [Indexed: 12/13/2022]
Abstract
Pathological studies of early Guillain-Barré syndrome (GBS), defined as of 10days of disease onset, are scanty making it difficult to interpret the physiopathology of clinical and electrophysiological features. In 1949, Webb Haymaker and James Kernohan reported 50 clinico-pathological studies of fatal GBS cases, 32 of them having died between days 2 and 10 after onset. They established that the brunt of initial lesions, consisting of endoneurial oedema interpreted as degenerative, relied on spinal nerves. That this oedema was inflammatory was soon thereafter recognized. Two decades later, however, the pathogenic role of endoneurial oedema was disputed. In experimental allergic neuritis, considered an animal model of GBS, the initial lesion appearing on day 4 post-inoculation is marked inflammatory oedema in the sciatic nerve and lumbosacral nerve roots. Additional detailed clinico-pathological studies corroborated that the appearance of epi-perineurium at the subarachnoid angle, where anterior and posterior roots join to form the spinal nerve, is a pathological hotspot in early GBS, there developing inflammatory oedema, incipient demyelination and endoneurial ischemic zones with axonal degeneration. Furthermore, nerve ultrasonography has demonstrated predominant spinal nerve changes in early GBS, either demyelinating or axonal. Other outstanding Haymaker and Kernohan's contributions were to clarify the complex nosology of the syndrome bringing under the same rubric Landry's paralysis, acute febrile polyneuritis and GBS, and critically analyzing GBS exclusion criteria by then prevailing. It is concluded that the authors' legacy remains as relevant as ever.
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Affiliation(s)
- José Berciano
- University of Cantabria, Service of Neurology, University Hospital "Marqués de Valdecilla (IDIVAL)", Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Santander, Spain.
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Abstract
BACKGROUND Guillain-Barré syndrome (GBS) is an acute paralysing disease caused by inflammation of the peripheral nerves, which corticosteroids would be expected to benefit. OBJECTIVES To examine the ability of corticosteroids to hasten recovery and reduce the long-term morbidity from GBS. SEARCH METHODS On 12 January 2016, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We also searched trials registries. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of any form of corticosteroid or adrenocorticotrophic hormone versus placebo or supportive care alone in GBS. Our primary outcome was change in disability grade on a seven-point scale after four weeks. Secondary outcomes included time from randomisation until recovery of unaided walking, time from randomisation until discontinuation of ventilation (for those ventilated), death, death or disability (inability to walk without aid) after 12 months, relapse, and adverse events. DATA COLLECTION AND ANALYSIS The review authors used standard methods expected by Cochrane. MAIN RESULTS The review authors discovered no new trials in the new searches in June 2009, November 2011, or January 2016. Six trials with 587 participants provided data for the primary outcome. According to moderate quality evidence, the disability grade change after four weeks in the corticosteroid groups was not significantly different from that in the control groups, mean difference (MD) 0.36 less improvement (95% confidence intervals (CI) 0.16 more to 0.88 less improvement). In four trials of oral corticosteroids with 120 participants in total, there was very low quality evidence of less improvement after four weeks with corticosteroids than without corticosteroids, MD 0.82 disability grades less improvement (95% CI 0.17 to 1.47 grades less). In two trials with a combined total of 467 participants, there was moderate quality evidence of no significant difference of a disability grade more improvement after four weeks with intravenous corticosteroids (MD 0.17, 95% CI -0.06 to 0.39). According to moderate quality evidence, there was also no significant difference between the corticosteroid treated and control groups for improvement by one or more grades after four weeks (risk ratio (RR) 1.08, 95% CI 0.93 to 1.24) or for death or disability after one year (RR 1.51, 95% CI 0.91 to 2.5). We found high quality evidence that the occurrence of diabetes was more common (RR 2.21, 95% CI 1.19 to 4.12) and hypertension less common (RR 0.15, 95% CI 0.05 to 0.41) in the corticosteroid-treated participants. AUTHORS' CONCLUSIONS According to moderate quality evidence, corticosteroids given alone do not significantly hasten recovery from GBS or affect the long-term outcome. According to very low quality evidence, oral corticosteroids delay recovery. Diabetes requiring insulin was more common and hypertension less common with corticosteroids based on high quality evidence.
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Affiliation(s)
- Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Angela A Gunn
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Pieter A van Doorn
- Erasmus University Medical CenterDepartment of NeurologyPO Box 2040RotterdamNetherlands3000 CA
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Proximal nerve lesions in early Guillain-Barré syndrome: implications for pathogenesis and disease classification. J Neurol 2016; 264:221-236. [PMID: 27314967 DOI: 10.1007/s00415-016-8204-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/10/2016] [Accepted: 06/10/2016] [Indexed: 12/13/2022]
Abstract
Guillain-Barré syndrome (GBS) is an acute-onset, immune-mediated disorder of the peripheral nervous system. In early GBS, arbitrarily established up to 10 days of disease onset, patients could exhibit selective manifestations due to involvement of the proximal nerves, including nerve roots, spinal nerves and plexuses. Such manifestations are proximal weakness, inaugural nerve trunk pain, and atypical electrophysiological patterns, which may lead to delayed diagnosis. The aim of this paper was to analyze the nosology of early GBS reviewing electrophysiological, autopsy and imaging studies, both in acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor/motor-sensory axonal neuropathy (AMAN/AMSAN). Early electrophysiology showed either well-defined demyelinating or axonal patterns, or a non-diagnostic pattern with abnormal late responses; there may be attenuated M responses upon lumbar root stimulation as the only finding. Pathological changes predominated in proximal nerves, in some studies, most prominent at the sides where the spinal roots unite to form the spinal nerves; on very early GBS endoneurial inflammatory edema was the outstanding feature. In the far majority of cases, spinal magnetic resonance imaging showed contrast enhancement of cauda equina, selectively involving anterior roots in AMAN. Both in AIDP and AMAN/AMSAN, ultrasonography has demonstrated frequent enlargement of ventral rami of C5-C7 nerves with blurred boundaries, whereas sonograms of upper and lower extremity peripheral nerves exhibited variable and less frequent abnormalities. We provide new insights into the pathogenesis and classification of early GBS.
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Successful control of radicular pain in a pediatric patient with Guillain-Barré syndrome. Brain Dev 2015; 37:897-900. [PMID: 25690256 DOI: 10.1016/j.braindev.2015.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 01/14/2015] [Accepted: 01/19/2015] [Indexed: 11/24/2022]
Abstract
A 10-year-old boy was diagnosed as having the axonal form of Guillain-Barré syndrome (GBS). The patient noticed progressive weakness of the lower legs on the 1st day of illness. Intravenous immunoglobulin therapy was immediately started on the 2nd day of illness. Despite the favorable recovery of muscle weakness, he complained of severe needle-like pain in the thighs and buttocks and also painful numbness over the gastrocnemius regions. Acetaminophen and hydroxyzine therapy was ineffective for the pain control. Oral prednisolone therapy (0.7 mg/kg/day) led to drastic pain-relief with favorable improvement of the weakness. Corticosteroid therapy is not typically used in the management of GBS patients. Although GBS-associated pain frequently occurs in children, only a few reports have indicated the analgesic utility of steroids in the treatment of pediatric GBS. This observation may suggest the alternative of this therapy as for the as the limited, but potentially rapid, control of GBS-associated acute radicular pain in pediatric patients.
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Pain management in Guillain–Barre syndrome: A systematic review. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2014.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Farmakidis C, Inan S, Milstein M, Herskovitz S. Headache and Pain in Guillain-Barré Syndrome. Curr Pain Headache Rep 2015; 19:40. [DOI: 10.1007/s11916-015-0508-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
BACKGROUND Pain in Guillain-Barré syndrome (GBS) is common, yet it is often under recognised and poorly managed. In recent years, a variety of pharmacological treatment options have been investigated in clinical trials for people with GBS-associated pain. This is an updated version of the original Cochrane review published in Issue 10, 2013. OBJECTIVES To assess the efficacy and safety of pharmacological treatments for various pain symptoms associated with GBS, during both the acute and convalescent (three months or more after onset) phases of GBS. SEARCH METHODS On 3 November 2014, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE. In addition, we searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs in participants with confirmed GBS, with pain assessment as either the primary or secondary outcome. For cross-over trials, an adequate washout period between phases was required for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy and assessed the risk of bias of each study. MAIN RESULTS Three short-term RCTs, which enrolled 277 randomised participants with acute phase GBS, were included. Risk of bias in the included studies was generally unclear due to insufficient information. None of the included studies reported the primary outcome selected for this review, which was number of patients with self reported pain relief of 50% or greater. One small study investigated seven-day regimens of gabapentin versus placebo. Pain was rated on a scale from 0 (no pain) to 10 (maximum pain). Amongst the 18 participants, significantly lower mean pain scores were found at the endpoint (day 7) in the gabapentin phase compared to the endpoint of the placebo phase (mean difference -3.61, 95% CI -4.12 to -3.10) (very low quality evidence). For adverse events, no significant differences were found in the incidence of nausea (risk ratio (RR) 0.50, 95% CI 0.05 to 5.04) or constipation (RR 0.14, 95% CI 0.01 to 2.54). A second study enrolling 36 participants compared gabapentin, carbamazepine and placebo, all administered over seven days. Participants in the gabapentin group had significantly lower median pain scores on all treatment days in comparison to the placebo and carbamazepine groups (P < 0.05). There were no statistically significant differences in the median pain scores between the carbamazepine and placebo groups from day 1 to day 3, but from day 4 until the end of the study significantly lower median pain scores were noted in the carbamazepine group (P < 0.05) (very low quality evidence). There were no adverse effects of gabapentin or carbamazepine reported, other than sedation. One large RCT (223 participants, all also treated with intravenous immunoglobulin), compared a five-day course of methylprednisolone with placebo and found no statistically significant differences in number of participants developing pain (RR 0.89, 95% CI 0.68 to 1.16), number of participants with decreased pain (RR 0.95, 95% CI 0.63 to 1.42) or number of participants with increased pain (RR 0.85, 95% CI 0.52 to 1.41) (low quality evidence). The study did not report whether there were any adverse events. AUTHORS' CONCLUSIONS Since the last version of this review we found no new studies. While management of pain in GBS is essential and pharmacotherapy is widely accepted as being an important component of treatment, this review does not provide sufficient evidence to support the use of any pharmacological intervention in people with pain in GBS. Although reductions in pain severity were found when comparing gabapentin and carbamazepine with placebo, the evidence was limited and its quality very low. Larger, well-designed RCTs are required to further investigate the efficacy and safety of potential interventions for patients with pain in GBS. Additionally, interventions for pain in the convalescent phase of GBS should be investigated.
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Affiliation(s)
- Jia Liu
- Xuanwu Hospital, Capital Medical UniversityDepartment of NeurologyChangchun Street 45BeijingChina100053
| | - Lu‐Ning Wang
- Chinese PLA General HospitalDepartment of Geriatric NeurologyFuxing Road 28Haidian DistrictBeijingChina100853
| | - Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMassachusettsUSA
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Peña L, Moreno CB, Gutierrez-Alvarez AM. Pain management in Guillain-Barre syndrome: a systematic review. Neurologia 2014; 30:433-8. [PMID: 24929444 DOI: 10.1016/j.nrl.2014.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 03/23/2014] [Accepted: 04/02/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Pain is a common symptom in patients with Guillain-Barre syndrome. Intensity is moderate to severe in most cases and pain may persist after resolution of the disease. OBJECTIVE Identify the most appropriate analgesic therapy for pain management in patients with Guillain-Barre syndrome. MATERIAL AND METHODS Systematic review and selection of scientific articles on treatment of pain in Guillain-Barre syndrome patients, published between January 1985 and December 2012. We included only randomised, double-blind, controlled trials assessing the effectiveness of drugs for pain management in these patients. RESULTS Four articles met the inclusion criteria. One evaluated the use of gabapentin, another evaluated carbamazepine, a third compared gabapentin to carbamazepine, and the last evaluated use of methylprednisolone. Both carbamazepine and gabapentin were useful for pain management. Patients experienced lower-intensity pain with gabapentin treatment in the study comparing that drug to carbamazepine. Methylprednisolone was not shown to be effective for reducing pain. The published data did not permit completion of a meta-analysis. CONCLUSIONS There is no robust evidence at present that would point to a single treatment option for this disorder. Further clinical studies of larger patient samples and with a longer duration are needed to characterise types of pain for each patient and measure pain intensity in an objective way.
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Affiliation(s)
- L Peña
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
| | - C B Moreno
- Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, Colombia
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Esquinas Requena JL, Fernández Martínez N, Martín Márquez J, Mazoteras Muñoz V, Martinón Torres G. [An atypical variant of Guillain-Barré syndrome: presentation of a case]. Rev Esp Geriatr Gerontol 2014; 49:91-93. [PMID: 24513438 DOI: 10.1016/j.regg.2013.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 11/27/2013] [Indexed: 06/03/2023]
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Abstract
BACKGROUND Pain in Guillain-Barré syndrome (GBS) is common, yet it is often under recognised and poorly managed. In recent years, a variety of pharmacological treatment options have been investigated in clinical trials for people with GBS-associated pain. OBJECTIVES To assess the efficacy and safety of pharmacological treatments for various pain symptoms associated with GBS, during both the acute and convalescent (three months or more after onset) phases of GBS. SEARCH METHODS On 27 August 2012, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2012, Issue 8) in The Cochrane Library, MEDLINE (January 1966 to August 2012) and EMBASE (January 1980 to August 2012). In addition, we searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs in participants with confirmed GBS, with pain assessment as either the primary or secondary outcome. For cross-over trials, an adequate washout period between phases was required for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified records, selected studies for inclusion, extracted eligible data, cross-checked the data for accuracy and assessed the risk of bias of each study. MAIN RESULTS Three short-term RCTs, which enrolled 277 randomised participants with acute phase GBS, were included. Risk of bias in the included studies was generally unclear due to insufficient information. None of the included studies reported the primary outcome selected for this review, which was number of patients with self reported pain relief of 50% or greater. One small study investigated seven-day regimens of gabapentin versus placebo. Pain was rated on a scale from 0 (no pain) to 10 (maximum pain). Amongst the 18 participants, significantly lower mean pain scores were found at the endpoint (day 7) in the gabapentin phase compared to the endpoint of the placebo phase (mean difference -3.61, 95% CI -4.12 to -3.10) (very low quality evidence). For adverse events, no significant differences were found in the incidence of nausea (risk ratio (RR) 0.50, 95% CI 0.05 to 5.04) or constipation (RR 0.14, 95% CI 0.01 to 2.54). A second study enrolling 36 participants compared gabapentin, carbamazepine and placebo, all administered over seven days. Participants in the gabapentin group had significantly lower median pain scores on all treatment days in comparison to the placebo and carbamazepine groups (P < 0.05). There were no statistically significant differences in the median pain scores between the carbamazepine and placebo groups from day 1 to day 3, but from day 4 until the end of the study significantly lower median pain scores were noted in the carbamazepine group (P < 0.05) (very low quality evidence). There were no adverse effects of gabapentin or carbamazepine reported other than sedation. One large RCT (223 participants, all also treated with intravenous immunoglobulin), compared a five-day course of methylprednisolone with placebo and found no statistically significant differences in number of participants developing pain (RR 0.89, 95% CI 0.68 to 1.16), number of participants with decreased pain (RR 0.95, 95% CI 0.63 to 1.42) or number of participants with increased pain (RR 0.85, 95% CI 0.52 to 1.41) (low quality evidence). The study did not report whether there were any adverse events. AUTHORS' CONCLUSIONS While management of pain in GBS is essential and pharmacotherapy is widely accepted as being an important component of treatment, this review does not provide sufficient evidence to support the use of any pharmacological intervention in people with pain in GBS. Although reductions in pain severity were found when comparing gabapentin and carbamazepine with placebo, the evidence was limited and its quality very low. Larger, well-designed RCTs are required to further investigate the efficacy and safety of potential interventions for patients with pain in GBS. Additionally, interventions for pain in the convalescent phase of GBS should be investigated.
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Affiliation(s)
- Jia Liu
- Department of Geriatric Neurology, Chinese PLA General Hospital, Fuxing Road 28, Beijing, China, 100853
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Endo K, Yasui K, Hasegawa Y, Yanagi T. [An adult Guillain-Barré syndrome patient with enhancement of anterior roots on spinal MRI and severe radicular pain relieved by intravenous methylprednisolone pulse therapy: A case report]. Rinsho Shinkeigaku 2013; 53:543-550. [PMID: 23892966 DOI: 10.5692/clinicalneurol.53.543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A 37-year-old man was admitted to our hospital because of progressive abnormal gait and severe pain in the low back and lower extremities, more severe on the right side, especially in his right posterior thigh. The pain appeared one week after he suffered from slight fever and diarrhea. On admission, a neurological examination revealed mild distal weakness of the all extremities and loss of Achilles tendon reflex, associated with positive Lasègue sign. However, sensation was intact except for slightly impaired vibratory sensation on the trunk. An electrophysiological study showed diminished amplitude of compound muscle action potential and loss of F-wave of the posterior tibial nerves. Finding of cerebrospinal fluid was normal at the time of admission, although 12 days later albuminocytologic dissociation was found. Cervical and lumbar magnetic resonance images showed gadolinium enhancement of the anterior nerve roots and the cauda equina, more prominent on the right side, correlating with the prominent side of the patient's leg pain. Because of neurological features, electrophysiological abnormalities and CSF findings, we diagnosed his illness as Guillain-Barré syndrome (GBS) characterized by severe back and leg pain. The character of pain was deep and aching, suggesting myalgic pain caused by the affected anterior roots. A short course high-dose intravenous immunoglobulin (IVIg) therapy was not effective against the radicular pain although minimal improvement of limb weakness occurred. Non-steroidal anti-inflammatory drugs and carbamazepine were unsuccessful for pain relief. Thereafter, intravenous methylprednisolone (IVMP) pulse therapy was introduced. On the day IVMP pulse therapy started, severe radicular pain began to decrease and became gradually milder without any marked effect on the other symptoms and signs of GBS.Moderate to severe pain is a common and early symptom of GBS and requires aggressive treatment. IVMP pulse therapy may be one of treatments for refractory and intolerable pain of GBS.
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Affiliation(s)
- Kuniyuki Endo
- Department of Neurology, Nagoya Daini Red Cross Hospital
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Abstract
The latest estimation for the frequency of Guillain-Barré syndrome (GBS) is 1.1 to 1.8 per 100000 persons per year. Guillain-Barré syndrome is today divided into two major subtypes: acute inflammatory demyelinating polyneuropathy (AIDP) and the axonal subtypes, acute motor axonal neuropathy (AMAN) and acute motor and sensory axonal neuropathy (AMSAN). The axonal forms of GBS are caused by certain autoimmune mechanisms, due to a molecular mimicry between antecedent bacterial infection (particularly Campylobacter jejuni) and human peripheral nerve gangliosides. Improvements in patient management in intensive care units has permitted a dramatic drop in mortality rates. Immunotherapy, including plasma exchange (PE) or intravenous immunoglobulin (IVIg), seems to shorten the time to recovery, but their effect remains limited. Further clinical investigations are needed to assess the effect of PE or IVIg on the GBS patients with mild affection, no response, or relapse.
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Affiliation(s)
- Harutoshi Fujimura
- Department of Neurology, Toneyama National Hospital, Toneyama, Toyonaka, Japan.
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Abstract
BACKGROUND Guillain-Barré syndrome (GBS) is an acute paralysing disease caused by inflammation of the peripheral nerves, which corticosteroids would be expected to benefit. OBJECTIVES To examine the ability of corticosteroids to hasten recovery and reduce the long-term morbidity from GBS. SEARCH METHODS We searched The Cochrane Neuromuscular Disease Group Specialized Register (1 November 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4), CENTRAL (2011, Issue 4), MEDLINE (January 1966 to October 2011) and EMBASE (January 1980 to October 2011). SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs of any form of corticosteroid or adrenocorticotrophic hormone in GBS. Our primary outcome was change in disability grade on a seven-point scale after four weeks. Secondary outcomes included time from randomisation until recovery of unaided walking, time from randomisation until discontinuation of ventilation (for those ventilated), death, death or disability (inability to walk without aid) after 12 months, relapse, and adverse events. DATA COLLECTION AND ANALYSIS Two authors extracted the data independently. MAIN RESULTS No new trials were discovered in the new searches in June 2009 or November 2011. Six trials with 587 participants provided data for the primary outcome. According to moderate quality evidence, the disability grade change after four weeks in the corticosteroid groups was not significantly different from that in the control groups, mean difference (MD) 0.36 less improvement (95% confidence intervals (CI) 0.16 more to 0.88 less improvement). In four trials of oral corticosteroids with 120 participants in total, there was significantly less improvement after four weeks with corticosteroids than without corticosteroids, MD 0.82 disability grades less improvement (95% CI 0.17 to 1.47). In two trials with a combined total of 467 participants, there was no significant difference, MD 0.17 (95% CI -0.06 to 0.39) of a disability grade more improvement after four weeks with intravenous corticosteroids. According to moderate to high quality evidence, there were no significant differences between the corticosteroid-treated and the control groups in any of the secondary efficacy outcomes. Diabetes was significantly more common and hypertension significantly much less common in the corticosteroid-treated participants. AUTHORS' CONCLUSIONS According to moderate quality evidence, corticosteroids given alone do not significantly hasten recovery from GBS or affect the long-term outcome. According to low quality evidence oral corticosteroids delay recovery. Diabetes requiring insulin was significantly more common and hypertension less common with corticosteroids.
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Affiliation(s)
- Richard A C Hughes
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK.
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Liu J, Wang LN, McNicol ED. Pharmacological treatment for pain in Guillain-Barré syndrome. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Chaparro LE, Wiffen PJ, Moore RA, Gilron I. Combination pharmacotherapy for the treatment of neuropathic pain in adults. Cochrane Database Syst Rev 2012; 2012:CD008943. [PMID: 22786518 PMCID: PMC6481651 DOI: 10.1002/14651858.cd008943.pub2] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pharmacotherapy remains an important modality for the treatment of neuropathic pain. However, as monotherapy current drugs are associated with limited efficacy and dose-related side effects. Combining two or more different drugs may improve analgesic efficacy and, in some situations, reduce overall side effects (e.g. if synergistic interactions allow for dose reductions of combined drugs). OBJECTIVES This review evaluated the efficacy, tolerability and safety of various drug combinations for the treatment of neuropathic pain. SEARCH METHODS We identified randomised controlled trials (RCTs) of various drug combinations for neuropathic pain from CENTRAL, MEDLINE, EMBASE and handsearches of other reviews and trial registries. The most recent search was performed on 9 April 2012. SELECTION CRITERIA Double-blind, randomised studies comparing combinations of two or more drugs (systemic or topical) to placebo and/or at least one other comparator for the treatment of neuropathic pain. DATA COLLECTION AND ANALYSIS Data extracted from each study included: proportion of participants a) reporting ≥ 30% pain reduction from baseline OR ≥ moderate pain relief OR ≥ moderate global improvement; b) dropping out of the trial due to treatment-emergent adverse effects; c) reporting each specific adverse effect (e.g. sedation, dizziness) of ≥ moderate severity. The primary comparison of interest was between study drug(s) and one or both single-agent comparators. We combined studies if they evaluated the same drug class combination at roughly similar doses and durations of treatment. We used RevMan 5 to analyse data for binary outcomes. MAIN RESULTS We identified 21 eligible studies: four (578 participants) evaluated the combination of an opioid with gabapentin or pregabalin; two (77 participants) evaluated an opioid with a tricyclic antidepressant; one (56 participants) of gabapentin and nortriptyline; one (120 participants) of gabapentin and alpha-lipoic acid, three (90 participants) of fluphenazine with a tricyclic antidepressant; three (90 participants) of an N-methyl-D-aspartate (NMDA) blocker with an agent from a different drug class; five (604 participants) of various topical medications; one (313 participants) of tramadol with acetaminophen; and another one (44 participants) of a cholecystokinin blocker (L-365,260) with morphine. The majority of combinations evaluated to date involve drugs, each of which share some element of central nervous system (CNS) depression (e.g. sedation, cognitive dysfunction). This aspect of side effect overlap between the combined agents was often reflected in similar or higher dropout rates for the combination and may thus substantially limit the utility of such drug combinations. Meta-analysis was possible for only one comparison of only one combination, i.e. gabapentin + opioid versus gabapentin alone. This meta-analysis involving 386 participants from two studies demonstrated modest, yet statistically significant, superiority of a gabapentin + opioid combination over gabapentin alone. However, this combination also produced significantly more frequent side effect-related trial dropouts compared to gabapentin alone. AUTHORS' CONCLUSIONS Multiple, good-quality studies demonstrate superior efficacy of two-drug combinations. However, the number of available studies for any one specific combination, as well as other study factors (e.g. limited trial size and duration), preclude the recommendation of any one specific drug combination for neuropathic pain. Demonstration of combination benefits by several studies together with reports of widespread clinical polypharmacy for neuropathic pain surely provide a rationale for additional future rigorous evaluations. In order to properly identify specific drug combinations which provide superior efficacy and/or safety, we recommend that future neuropathic pain studies of two-drug combinations include comparisons with placebo and both single-agent components. Given the apparent adverse impact of combining agents with similar adverse effect profiles (e.g. CNS depression), the anticipated development and availability of non-sedating neuropathic pain agents could lead to the identification of more favourable analgesic drug combinations in which side effects are not compounded.
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Affiliation(s)
- Nobuhiro Yuki
- Department of Medicine, National University of Singapore, Singapore.
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Abstract
Evaluation of: Ruts L, Drenthen J, Jongen JL et al. Pain in Guillain-Barré syndrome: a long-term follow-up study. Neurology 75, 1439-1447 (2010). Pain has been recognized as an important symptom of Guillain-Barré syndrome (GBS). The article under review prospectively studied the phenomenon of pain in a cohort of 156 GBS patients for a period of 1 year. It confirmed that pain of significant intensity is relatively common in all subtypes of GBS. It may start before the onset of other symptoms. It correlates with sensory loss, severity of the GBS at its nadir and the presence of diarrhea. In the recovery/chronic stages it correlates with weakness, disability and fatigue. Up to a third of patients have pain at 1 year.
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Lehmann HC, Meyer Zu Horste G, Kieseier BC, Hartung HP. Pathogenesis and treatment of immune-mediated neuropathies. Ther Adv Neurol Disord 2011; 2:261-81. [PMID: 21179533 DOI: 10.1177/1756285609104792] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Immune-mediated neuropathies represent a heterogeneous spectrum of peripheral nerve disorders that can be classified according to time course, predominant involvement of motor/sensory fibers, distribution of deficits and paraclinical parameters such as electrophysiology and serum antibodies. In the last few years, significant advances have been achieved in elucidating underlying pathomechanisms, which made it possible to identify potential therapeutic targets. In this review, we discuss the latest development in pathogenesis and treatment of immune-mediated neuropathies.
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Pazzaglia C, Briani C, Nobile-Orazio E, Orazio EN, Caliandro P, Granata G, Tonali PA, Padua L. Occurrence and characterization of Pain in immune-mediated neuropathies: a multicentre prospective study. Eur J Neurol 2011; 18:177-83. [PMID: 20561036 DOI: 10.1111/j.1468-1331.2010.03108.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND pain is a common symptom of peripheral neuropathies that may severely affect patients' Quality of Life. Pain questionnaires, based on verbal descriptors, are a useful way to investigate it. METHODS we performed a multicentre study through validated measures to characterize pain in a sample of consecutive patients affected by immune-mediated neuropathies. RESULTS ninety-three patients were enrolled in 16 Italian centres. Based on the numeric rating scale, almost half of the patients complained of moderate pain and one-third of the patients severe pain. Overall, up to 50% of our patients with immune-mediated neuropathies complained of neuropathic pain. The most common neuropathic symptoms were paraesthesia/dysesthesia and superficial spontaneous pain. Surprisingly, also patients with neuropathies commonly thought to be painless (such as multifocal motor neuropathy) reported discomfort and painful symptoms. CONCLUSIONS pain questionnaires should be considered in the clinical evaluation of immune-mediated neuropathies, also when evaluating therapy efficacy, because they may provide clinicians with useful information on painful symptoms and patients' quality of life.
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Affiliation(s)
- C Pazzaglia
- Department of Neurosciences, Institute of Neurology, Catholic University, Rome, Italy.
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Abstract
Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in the developed world. Guillain-Barré syndrome typically presents with ascending paralysis and is usually severe enough to warrant hospital admission for management. In the United States alone, GBS results in more than 6000 hospitalizations each year. Although GBS patients were historically cared for at tertiary referral centers, changing treatment practices have broadened the number of neurologists who care for the disease. This article provides a review of key issues in the inpatient management of GBS. A survey of the evidence base for treatment with plasma exchange or intravenous immunoglobulins is presented. Although either of these treatments can limit the severity of GBS, patients are still at risk for a broad range of complications, including respiratory failure, autonomic dysfunction, thromboembolic disease, pain, and psychiatric disorders. Awareness of these complications, their detection and management, may help limit the morbidity of GBS.
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Affiliation(s)
- Matthew Harms
- Department of Neurology, Washington University School of Medicine, St Louis, MO, USA
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Binder A, Baron R. Size matters - small fiber neuropathy in the Guillain-Barré syndrome. Pain 2010; 151:9-10. [PMID: 20591570 DOI: 10.1016/j.pain.2010.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 06/11/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Andreas Binder
- Sektion Neurologische Schmerzforschung und Therapie, Klinik für Neurologie, Christian-Albrechts-Universität Kiel, Germany
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Kuitwaard K, Bos-Eyssen ME, Blomkwist-Markens PH, van Doorn PA. Recurrences, vaccinations and long-term symptoms in GBS and CIDP. J Peripher Nerv Syst 2010; 14:310-5. [PMID: 20021573 DOI: 10.1111/j.1529-8027.2009.00243.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We determined the frequency of recurrent Guillain-Barré syndrome (GBS), whether vaccinations led to recurrences of GBS or an increase of disability in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and we assessed the prevalence of pain, fatigue and the impact on quality of life after GBS and CIDP. Additionally, we assessed the presence of common auto-immune disorders. Four hundred and sixty-one members of the Dutch society of neuromuscular disorders received a questionnaire. Two hundred and forty-five GBS and seventy-six CIDP patients were included (response rate 70%). Nine patients had a confirmed recurrent GBS, and two patients had experienced both GBS and CIDP. Common auto-immune diseases were reported in 9% of GBS and 5% of CIDP patients. None of the 106 GBS patients who received a flu vaccination (range 1-37 times, total 775 vaccinations) reported a recurrence thereafter. Five out of twenty-four CIDP patients who received a flu vaccination (range 1-17 times) reported an increase in symptoms. Pain or severe fatigue was reported in about 70% of patients after the diagnosis of GBS (median 10 years) or after onset of CIDP (median 6 years), and quality of life was significantly reduced. Flu vaccinations seem relatively safe. GBS and CIDP patients often experience pain, fatigue and a reduced quality of life for many years after the diagnosis.
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Affiliation(s)
- Krista Kuitwaard
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
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Inatomi Y, Yonehara T, Hirano T, Uchino M. Miller Fisher Syndrome Presenting with Pain on Eye Movement. Neuroophthalmology 2010. [DOI: 10.3109/01658100903470553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ruts L, Rico R, van Koningsveld R, Botero JD, Meulstee J, Gerstenbluth I, Merkies ISJ, van Doorn PA. Pain accompanies pure motor Guillain-Barré syndrome. J Peripher Nerv Syst 2009; 13:305-6. [PMID: 19192071 DOI: 10.1111/j.1529-8027.2008.00197.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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van Doorn PA, Ruts L, Jacobs BC. Clinical features, pathogenesis, and treatment of Guillain-Barré syndrome. Lancet Neurol 2008; 7:939-50. [PMID: 18848313 DOI: 10.1016/s1474-4422(08)70215-1] [Citation(s) in RCA: 496] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Guillain-Barré syndrome (GBS) is an important cause of acute neuromuscular paralysis. Molecular mimicry and a cross-reactive immune response play a crucial part in its pathogenesis, at least in those cases with a preceding Campylobacter jejuni infection and with antibodies to gangliosides. The type of preceding infection and patient-related host factors seem to determine the form and severity of the disease. Intravenous immunoglobulin (IVIg) and plasma exchange are effective treatments in GBS; mainly for practical reasons, IVIg is the preferred treatment. Whether mildly affected patients or patients with Miller Fisher syndrome also benefit from IVIg is unclear. Despite medical treatment, GBS often remains a severe disease; 3-10% of patients die and 20% are still unable to walk after 6 months. In addition, many patients have pain and fatigue that can persist for months or years. Advances in prognostic modelling have resulted in the development of a new and simple prognostic outcome scale that might also help to guide new treatment options, particularly in patients with GBS who have a poor prognosis.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus Medical Centre, Rotterdam, Netherlands.
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How to assess new drugs for neuropathies: advances in trial design and methodology. Curr Opin Neurol 2008; 21:519-26. [DOI: 10.1097/wco.0b013e32830f1e3b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Current world literature. Curr Opin Neurol 2008; 21:615-24. [PMID: 18769258 DOI: 10.1097/wco.0b013e32830fb782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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39
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Ruts L, van Doorn PA, Blankevoort JP, Prens EP. Transient hypertrichosis in a patient with Guillain-Barré syndrome. J Peripher Nerv Syst 2008; 12:290-2. [PMID: 18042141 DOI: 10.1111/j.1529-8027.2007.00152.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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