Electrodiagnostic criteria for Guillain-Barrè syndrome: a critical revision and the need for an update

Combined Central and Peripheral Demyelination (CCPD) Associated with MOG Antibodies: Report of Four New Cases and Narrative Review of the Literature

Background/Objectives: Myelin oligodendrocyte glycoprotein (MOG) is exclusively expressed in the central nervous system (CNS) and is found on the outer surface of oligodendrocytes. Antibodies to MOG are associated with CNS demyelination, whereas peripheral nervous system (PNS) demyelination is seldom reported to be related to MOG-IgG. Methods: The database of patients seen in our neurological academic center was searched for MOG-IgG seropositivity and concomitant demyelinating polyneuropathy. For the purpose of the review, in March 2024, we searched for case reports and case series in the following databases: PubMed, Scopus, Cochrane, and ScienceDirect. Inclusion criteria were MOG-IgG seropositivity and demyelinating polyneuropathy. Exclusion criteria were type of publication other than case reports and case series, unconfirmed diagnosis of demyelinating polyneuropathy, and other diseases causing demyelination in either the CNS or PNS. Critical appraisal of the selected case reports and case series was realized by JBI. Results: Four new cases were identified with MOG-IgG and confirmed demyelinating polyneuropathy. This review identified 22 cases that have been published since 2018. Clinical, imaging, neurophysiological, and immunological characteristics, as well as treatment options and outcomes are presented and compared to those of other cases with combined central and peripheral demyelination (CCPD). Conclusions: The pathogenetic mechanism is unclear; thus, different hypotheses are discussed. New case reporting and large cohort studies will help further the exploration of the underlying mechanism and guide more effective therapeutic interventions.

Guillain-Barré syndrome after surgery: a literature review

Guillain-Barré syndrome (GBS) is a rare postoperative complication that is sometimes characterized by serious motor weakness and prolonged weaning from mechanical ventilation. Although the exact nature of the relationship between GBS and the surgical procedure is still unclear, there is a clear increased incidence of GBS in post-surgical patients compared to non-surgical patients. GBS after surgery is unique in several ways. The course of post-surgical GBS unfolds more rapidly than in other situations where GBS develops, the condition is often more severe, and respiratory muscles are more commonly involved. Prompt diagnosis and appropriate treatment are essential, and the condition can worsen if treated inappropriately. Postoperative sedation, intubation, and restraint use make the diagnosis of GBS difficult, as the onset of symptoms of weakness or numbness in those contexts are not obvious. GBS is often misdiagnosed, being attributed to other postoperative complications, and subsequently mishandled. The lack of relevant information further obscures the clinical picture. We sought to better understand post-surgical GBS by performing an analysis of the relevant literature, focusing on clearly documenting the clinical characteristics, diagnosis, and management of GBS that emerges following surgery. We underscore the importance of physicians being aware of the possibility of GBS after major surgery and of performing a variety of laboratory clinical investigations early on in suspected cases.

The sural-sparing pattern in clinical variants and electrophysiological subtypes of Guillain-Barré syndrome

BACKGROUND

 Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis worldwide and can be classified into electrophysiological subtypes and clinical variants.

OBJECTIVE

 This study aimed to compare the frequency of the sural-sparing pattern (SSP) in subtypes and variants of GBS.

METHODS

 This retrospective cohort study analyzed clinical and electrophysiological data of 171 patients with GBS hospitalized in public and private hospitals of Natal, Rio Grande do Norte, Brazil, between 1994 and 2018; all cases were followed up by the same neurologist in a reference neurology center. Patients were classified according to electrophysiological subtypes and clinical variants, and the SSP frequency was compared in both categories. The exact Fisher test and Bonferroni correction were used for statistical analysis.

RESULTS

 The SSP was present in 53% (57 of 107) of the patients with acute inflammatory demyelinating polyradiculoneuropathy (AIDP), 8% (4 of 48) of the patients with axonal subtypes, and 31% (5 of 16) of the equivocal cases. The SSP frequency in the AIDP was significantly higher than in the axonal subtypes (p < 0.0001); the value was kept high after serial electrophysiological examinations. Only the paraparetic subtype did not present SSP.

CONCLUSION

 The SSP may be present in AIDP and axonal subtypes, including acute motor axonal neuropathy, but it is significantly more present in AIDP. Moreover, the clinical variants reflect a specific pathological process and are correlated to its typical electrophysiological subtype, affecting the SSP frequency.

Dynamics and prognostic value of serum neurofilament light chain in Guillain-Barré syndrome

BACKGROUND

Neurofilament light chain (NfL) is a biomarker for axonal damage in several neurological disorders. We studied the longitudinal changes in serum NfL in patients with Guillain-Barré syndrome (GBS) in relation to disease severity, electrophysiological subtype, treatment response, and prognosis.

METHODS

We included patients with GBS who participated in a double-blind, randomised, placebo-controlled trial that evaluated the effects of a second course of intravenous immunoglobulin (IVIg) on clinical outcomes. Serum NfL levels were measured before initiation of treatment and at one, two, four, and twelve weeks using a Simoa HD-X Analyzer. Serum NfL dynamics were analysed using linear mixed-effects models. Logistic regression was employed to determine the associations of serum NfL with clinical outcome and the prognostic value of serum NfL after correcting for known prognostic markers included in the modified Erasmus GBS Outcome Score (mEGOS).

FINDINGS

NfL levels were tested in serum from 281 patients. Serum NfL dynamics were associated with disease severity and electrophysiological subtype. Strong associations were found between high levels of serum NfL at two weeks and inability to walk unaided at four weeks (OR = 1.74, 95% CI = 1.27-2.45), and high serum NfL levels at four weeks and inability to walk unaided at 26 weeks (OR = 2.79, 95% CI = 1.72-4.90). Baseline serum NfL had the most significant prognostic value for ability to walk, independent of predictors included in the mEGOS. The time to regain ability to walk unaided was significantly longer for patients with highest serum NfL levels at baseline (p = 0.0048) and week 2 (p < 0.0001). No differences in serum NfL were observed between patients that received a second IVIg course vs. IVIg and placebo.

INTERPRETATION

Serum NfL levels are associated with disease severity, axonal involvement, and poor outcome in GBS. Serum NfL potentially represents a biomarker to monitor neuronal damage in GBS and an intermediate endpoint to evaluate the effects of treatment.

FUNDING

Prinses Beatrix Spierfonds W.OR19-24.

Electrodiagnostic methods to verify Guillain-Barré syndrome subtypes in Istanbul: A prospective multicenter study

BACKGROUND AND AIMS

This study aimed to identify the clinical characteristics and electrodiagnostic subtypes of Guillain-Barré syndrome (GBS) in Istanbul.

METHODS

Patients with GBS were prospectively recruited between April 2019 and March 2022 and two electrodiagnostic examinations were performed on each patient. The criteria of Ho et al., Hadden et al., Rajabally et al., and Uncini et al. were compared for the differentiation of demyelinating and axonal subtypes, and their relations with anti-ganglioside antibodies were analyzed.

RESULTS

One hundred seventy-seven patients were included, 69 before the coronavirus disease 2019 pandemic (April 2019-February 2020) and 108 during the pandemic (March 2020-March 2022), without substantial changes in monthly frequencies. As compared with the criteria of Uncini et al., demyelinating GBS subtype diagnosis was more frequent according to the Ho et al. and Hadden et al. criteria (95/162, 58.6% vs. 110/174, 63.2% and 121/174, 69.5%, respectively), and less frequent according to Rajabally et al.'s criteria (76/174, 43.7%). Fourteen patients' diagnoses made using Rajabally et al.'s criteria were shifted to the other subtype with the second electrodiagnostic examination. Of the 106 analyzed patients, 22 had immunoglobulin G anti-ganglioside antibodies (14 with the axonal subtype). They had less frequent sensory symptoms (54.5% vs. 83.1%, p = 0.009), a more frequent history of previous gastroenteritis (54.5% vs. 22.9%, p = 0.007), and a more severe disease as compared with those without antibodies.

INTERPRETATION

Serial electrodiagnostic examinations are more helpful for accurate subtype diagnosis of GBS because of the dynamic pathophysiology of the disease. We observed no significant increase in GBS frequency during the pandemic in this metropolis.

Nodal Conduction Block and Internodal Conduction Block in Nodopathy

OBJECTIVES

In 2015, a new term "nodopathy" was introduced to represent a group of neuropathy because of autoantibodies at the node of Ranvier and paranodal area. This review was conducted to highlight the electrophysiologic characteristics of acute and chronic nodopathies by the newly introduced term: "nodal conduction block (CB); CB without temporal dispersion or slow nerve conduction velocity" and by introducing a new term: "internodal CB; CB with temporal dispersion or/and slow nerve conduction velocity".

METHODS

Through PubMed searches, 23 cases of acute (<4 weeks of neuropathy) nodopathy and 12 cases of chronic (>4 weeks of neuropathy) nodopathy are identified. Two other required inclusion criteria are positive nodal antibody test and detailed nerve conduction data with or without figure. All existing data were analyzed to see whether these cases had nodal or internodal CB.

RESULTS

Among 23 cases of acute nodopathy, 11 had nodal CB, 9 internodal CB, and 3 mixed CB. Thus, nodal CB was observed in 61% of acute nodopathy cases and internodal CB in 52% of acute nodopathy cases. Among 12 cases of chronic nodopathy, all 12 had internodal CB.

CONCLUSIONS

Nodal CB is the nerve conduction characteristic of acute nodopathy, but internodal CB does not rule out acute nodopathy. Internodal CB is the nerve conduction characteristic of chronic nodopathy.

A recent surge of nitrous oxide misuse around London which merits a public health warning

BACKGROUND

Use of nitrous oxide (N2O) gas for recreational purposes by young people is increasingly recognized as a public health hazard in the UK.

METHODS

We looked at the hospital records of patients admitted over the last 4 years to a single neurological centre in Essex to determine the demographics, presentation, and management of patients presenting with symptoms of N2O toxicity from its recreational use.

RESULTS

Of the 17 patients (mean age = 22.9 ± 3 years) admitted between September 2018 and October 2022, 70% were admitted between January and October 2022. All patients reported limb paraesthesiae and 16/17 reported (95%) imbalance; 11/17 (65%) showed objective limb weakness. Serum B12 concentration was low in 9/17 (53%). Plasma methylmalonic acid (n = 7) and homocysteine (n = 8) levels were elevated in all patients tested. Spinal cord Magnetic Resonance Imaging (MRI) imaging was abnormal in 10/17 (59%) patients. Nerve conduction studies were abnormal in 10/13 (77%) patients, with evidence of a symmetric, length-dependent, large fibre neuropathy.

CONCLUSIONS

There has been a recent surge of cases with neurological complications of recreational N2O abuse in the UK, with a relatively greater rate in 2022. Greater awareness of this condition amongst clinicians and health regulators is urgently required to prevent harm from N2O misuse in young people.

An Unusual Presentation of the Cervicobrachial Variant of Guillain-Barré Syndrome in a 32-Year-Old Previously Healthy Male

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder characterized by acute peripheral nerve demyelination. The cervicobrachial (CB) variant presents with predominant upper limb weakness and has distinct clinical features. This case report aims to detail the clinical manifestations, diagnostic methodology, treatment outcomes, and broader implications of the CB variant of GBS. This case report presents a 32-year-old male, with a rare CB type of GBS, characterized by upper limb weakness and distinctive clinical features. Following a recent flu-like illness, the patient exhibited sudden onset weakness and neck pain. Neurological examination revealed proximal muscle weakness in the upper limbs with associated impaired pinprick sensation. Relevant laboratory investigations and imaging supported the diagnosis. The patient was diagnosed based on clinical suspicion, presentation, and cerebrospinal fluid (CSF) albuminocytological dissociation. The patient responded to intravenous immunoglobulin (IVIG) therapy, highlighting the importance of early recognition and intervention. The diagnostic approach involved nerve conduction studies (NCS), CSF analysis, and imaging, with normal findings on CT, MRI brain & cervical spine, and NCS. IVIG therapy resulted in significant improvement in muscle power. In conclusion, this case shows the significance of early recognition and intervention in the CB variant of GBS. The diagnostic methodology, encompassing advanced modalities, played a crucial role in confirming the diagnosis.

Factors Predicting Prolonged Mechanical Ventilation in Guillain-Barré Syndrome

BACKGROUND

Up to 30% of patients with Guillain-Barré syndrome require mechanical ventilation and 5% die due to acute complications of mechanical ventilation. There is a considerable group of patients that will need prolonged mechanical ventilation (considered as >14 days) and should be considered for early tracheostomy. The objective of this study is to identify risk factors for prolonged mechanical ventilation.

METHODS

We prospectively analyzed patients with Guillain-Barré diagnosis with versus without prolonged mechanical ventilation. We considered clinical and electrophysiological characteristics and analyzed factors associated with prolonged mechanical ventilation.

RESULTS

Three hundred and three patients were included; 29% required mechanical ventilation. When comparing the groups, patients with prolonged invasive mechanical ventilation (IMV) have a lower score on the Medical Research Council score (19.5 ± 16.2 vs 27.4 ± 17.5, p = 0.03) and a higher frequency of dysautonomia (42.3% vs 19.4%, p = 0.037), as well as lower amplitudes of the distal compound muscle action potential (CMAP) of the median nerve [0.37 (RIQ 0.07-2.25) vs. 3.9 (RIQ1.2-6.4), p = <0.001] and ulnar nerve [0.37 (RIQ0.0-3.72) vs 1.5 (RIQ0.3-6.6), p = <0.001], and higher frequency of severe axonal damage in these nerves (distal CMAP ≤ 1.0 mV). Through binary logistic regression, severe axonal degeneration of the median nerve is an independent risk factor for prolonged IMV OR 4.9 (95%CI 1.1-21.5) p = 0.03, AUC of 0.774, (95%CI 0.66-0.88), p = < 0.001.

CONCLUSIONS

Severe median nerve damage is an independent risk factor for prolonged mechanical ventilation.

Guillain-Barré Syndrome

OBJECTIVE

This article summarizes the clinical features, diagnostic criteria, differential diagnosis, pathogenesis, and prognosis of Guillain-Barré syndrome (GBS), with insights into the current and future diagnostic and therapeutic interventions for this neuromuscular syndrome.

LATEST DEVELOPMENTS

GBS is an acute, inflammatory, immune-mediated polyradiculoneuropathy that encompasses many clinical variants and divergent pathogenic mechanisms that lead to axonal, demyelinating, or mixed findings on electrodiagnostic studies. The type of antecedent infection, the development of pathogenic cross-reactive antibodies via molecular mimicry, and the location of the target gangliosides affect the subtype and severity of the illness. The data from the International GBS Outcome Study have highlighted regional variances, provided new and internationally validated prognosis tools that are beneficial for counseling, and introduced a platform for discussion of GBS-related open questions. New research has been undertaken, including research on novel diagnostic and therapeutic biomarkers, which may lead to new therapies.

ESSENTIAL POINTS

GBS is among the most frequent life-threatening neuromuscular emergencies in the world. At least 20% of patients with GBS have a poor prognosis and significant residual deficits despite receiving available treatments. Research is ongoing to further understand the pathogenesis of the disorder, find new biomarkers, and develop more effective and specific treatments.

The Rise Slope of the Compound Sensory Nerve Action Potential in Normal and Pathological Human Nerves

In spite of the diagnostic importance of the early phase of the sensory nerve action potential (SNAP), reliable electrodiagnostic metrics for this part of the recorded waveform are lacking. The average rise slope of the SNAP appreciates the steepness of the initial negative deflection of the waveform, which might be a useful metric for the first part of the potential. Sural nerve sensory neurography was performed in patients with various axonal neuropathies, and median nerve sensory studies were carried out in patients with carpal tunnel syndrome. Age-matched healthy individuals served as controls. The rise slope was compared to conventional SNAP parameters such as conduction velocity, latency, duration, and rise time. Overall, 537 sensory studies were prospectively analyzed. The rise slope of the sural SNAP demonstrated superior classification performance in terms of sensitivity (92.5%), specificity (97%), and area under the receiver operating characteristic curve (0.986), as compared to conventional SNAP parameters. Its diagnostic power was similarly excellent in median nerve studies, whereas here a slightly better classification performance was obtained by SNAP latency and conduction velocity. The average rise slope appears to do justice to the tight interplay between amplitude and rise time of the initial negative spike deflection, outperforming many conventional measures. This composite metric proved high diagnostic potency in particular with regard to axonal sensory nerve dysfunction.

Immune-mediated polyneuropathy in cats: Clinical description, electrodiagnostic assessment, and treatment

BACKGROUND

Suspected immune-mediated polyneuropathy has been increasingly reported in cats, especially in the last decade, but the condition remains poorly understood.

OBJECTIVES

Refine the clinical description and review the classification of this condition based on electrodiagnostic investigation and evaluate the benefit of corticosteroid treatment and L-carnitine supplementation.

ANIMALS

Fifty-five cats presented with signs of muscular weakness and electrodiagnostic findings consistent with polyneuropathy of unknown origin.

METHODS

Retrospective, multicenter study. Data from the medical records were reviewed. The owners were contacted by phone for follow-up at the time of the study.

RESULTS

The male-to-female ratio was 2.2. The median age of onset was 10 months, with 91% of affected cats being <3 years of age. Fourteen breeds were represented in the study. The electrodiagnostic findings supported purely motor axonal polyneuropathy. Histological findings from nerve biopsies were consistent with immune-mediated neuropathy in 87% of the tested cats. The overall prognosis for recovery was good to excellent, as all but 1 cat achieved clinical recovery, with 12% having mild sequelae and 28% having multiple episodes during their lifetime. The outcome was similar in cats with no treatment when compared with cats receiving corticosteroids or L-carnitine supplementation.

CONCLUSIONS AND CLINICAL IMPORTANCE

Immune-mediated motor axonal polyneuropathy should be considered in young cats with muscle weakness. This condition may be similar to acute motor axonal neuropathy in Guillain-Barré syndrome patients. Based on our results, diagnostic criteria have been proposed.

Immune-Mediated Neuropathies: Pathophysiology and Management

Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.

Study of total duration of distal compound muscle action potential in demyelinating and axonal Guillain-Barre' syndrome

OBJECTIVES

Electrophysiology plays a crucial role in Guillain-Barré syndrome (GBS) diagnosis and subtype classification. The aim of our study was to assess the potential role of distal compound muscle action potential (dCMAP) for early differentiation between acute inflammatory demyelinating polyneuropathy (AIDP) and axonal GBS.

METHODS

We retrospectively reviewed the medical records of 24 subjects with AIDP and 18 subjects with axonal GBS. We built up receiver operating characteristic curves for total dCMAP duration and negative phase of dCMAP duration, in order to derive cut-off values able to differentiate between AIDP and axonal GBS.

RESULTS

The total duration of dCMAP was significantly prolonged in AIDP compared to axonal GBS. AUCs, odds ratio and positive predictive values were higher for total duration than for negative peak duration. Nerve conduction parameters in the lower limbs were more sensitive than those in the upper limbs in distinguishing AIDP from axonal GBS.

DISCUSSION

Total duration of dCMAP dispersion may capture an adjunctive component of distal demyelination, not measured by the more traditional parameters and may thus represent a useful tool for early differentiation between AIDP and axonal GBS.

Association between hyperCKemia and axonal degeneration in Guillain-Barré syndrome

BACKGROUND

Elevated serum creatine kinase (CK) levels have been reported in patients with Guillain-Barré syndrome (GBS), more frequently in patients with acute motor axonal neuropathy (AMAN) than in those with acute inflammatory demyelinating polyneuropathy (AIDP). However, some patients with AMAN show reversible conduction failure (RCF), characterized by rapid recovery without axonal degeneration. The present study tested the hypothesis that hyperCKemia is associated with axonal degeneration in GBS, regardless of the subtype.

METHODS

We retrospectively enrolled 54 patients with AIDP or AMAN whose serum CK levels were measured within 4 weeks from symptom onset between January 2011 and January 2021. We divided them into hyperCKemia (serum CK ≥ 200 IU/L) and normal CK (serum CK < 200 IU/L) groups. Patients were further classified into axonal degeneration and RCF groups based on more than two nerve conduction studies. The clinical features and frequency of axonal degeneration and RCF were compared between groups.

RESULTS

Clinical characteristics were similar in the hyperCKemia and normal CK groups. Compared with that in the RCF subgroup, the frequency of hyperCKemia was significantly higher in the axonal degeneration group (p = 0.007). Patients with normal serum CK levels showed better clinical prognosis, evaluated by the Hughes score at 6 months from admission (p = 0.037).

CONCLUSION

HyperCKemia is associated with axonal degeneration in GBS, regardless of the electrophysiological subtype. HyperCKemia within 4 weeks from symptom onset might be a marker of axonal degeneration and poor prognosis in GBS. Serial nerve conduction studies and serum CK measurements will help clinicians understand the pathophysiology of GBS.

Critical illness-associated weakness and related motor disorders

Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.

Clinical Features and Outcome of the Guillain–Barre Syndrome: A Single-Center 11-Year Experience

Background

Clinical presentation, electrophysiological subtype, and outcome of the Guillain–Barre' Syndrome (GBS) may differ between patients from different geographical regions. This study aims to assess clinical–neurophysiological features of an adult, Italian GBS cohort over 11 years.

Methods

Retrospective (from 1 January 2011 to 31 December 2021) analysis was carried out on patients admitted to the Siena University Hospital who fulfilled the GBS diagnostic criteria. Demographic data, clinical characteristics, treatment, need of mechanical ventilation (MV), laboratory and electrophysiological tests, preceding infections/vaccination/other conditions, and comorbidities were collected for each patient.

Results

A total of 84 patients (51 men, median age of 61 years), were identified. GBS subtype was classified as acute inflammatory demyelinating polyneuropathy (AIDP) in the 66.6% of patients, acute motor/sensory axonal neuropathy (AMAN/AMSAN) in 20.2%, and the Miller Fisher syndrome in 5 (5.9%). Flu syndrome and gastrointestinal infection were the most common preceding conditions. In total, five (5.9%) subjects had concomitant cytomegalovirus (CMV) infection. Cranial nerve involvement occurred in 34.5% of subjects. Differences between the axonal and AIDP forms of GBS concerned the presence of anti-ganglioside antibodies. In total, seven (8.33%) patients required MV.

Discussion

The epidemiological and clinical characteristics of GBS in different countries are constantly evolving, especially in relation to environmental changes. This study provides updated clinical-epidemiological information in an Italian cohort.

Chronic inflammatory demyelinating polyneuropathy with an acute onset. Clinical case

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a heterogeneous treatable dysimmune neuropathy. The variety of clinical forms and course of the disease can be challenging for proper diagnosis and early treatment. In a quarter of cases CIDP starts acutely, mimicking GuillainBarr syndrome. The early diagnosis is especially important regarding differences in treatment and prognosis of these conditions. In this article, we present a clinical case of acute onset CIDP with a detailed analysis of the differential diagnosis between acute and chronic immune-mediated neuropathies.

Nodopathies in the Early Diagnosis of Axonal Forms of Guillain-Barré Syndrome

Introduction:

Guillain-Barré syndrome (GBS) has been classified into demyelinating and axonal subtypes or forms, such as acute motor axonal neuropathy (AMAN) and regional pharyngeal-cervical-brachial variant (PCBv).

Objective

To study the relationship between motor nerve conduction blocks (CBs) and prognosis in AMAN and PCBv.

Patients and Methods

We retrospectively analyzed six cases of AMAN and PCBv with serial nerve conduction studies (NCS) and electromyography (EMG).

Results

The serial NCS (1st−2nd and 3rd week) showed, as the most constant data, a decreased amplitude of the compound muscle action potential (CMAP) in 100% of cases. CBs were present in 66.6% of cases. EMG (3rd week) showed signs of severe denervation in 33.3%. All patients were treated from the 1st−2nd week of evolution with intravenous immunoglobulins (IVIGs). Patients with CBs (1st−2nd and 3rd week), showed reversible CBs or reversible conduction failure (RCF) and complete recovery at 1 month. Patients without CBs, with persistent reduced distal CMAP amplitude (dCMAP), showed severe acute denervation due to axonal degeneration (3rd week and 1st−3rd month) and a slow recovery of several months.

Conclusions

Not all axonal forms of GBS have a poor prognosis. This study of AMAN and PCBv shows that patients with CBs can have reversible CBs or RCF, and good prognosis. Patients without CBs, with persistent reduction of dCMAP amplitude decrement, have severe acute denervation, and a worse prognosis. AMAN and PCBv have a continuous spectrum ranging from CBs due to dysfunction/disruption of Nodes of Ranvier, called nodopathies, with reversible CBs or RCF and good prognosis, to axonal degeneration with worse prognosis.

Clinical and Electrophysiological Factors Predicting Prolonged Recovery in Children with Guillain-Barré Syndrome

OBJECTIVE

To compare clinical and nerve conduction studies (NCS) parameters predictive of outcome in children with acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor axonal neuropathy (AMAN).

METHODS

In this prospective observational study, NCS was done on all children at admission and repeated before discharge. Functional status of patients was graded as per Hughes Disability score. These children were followed up till they achieved independent walking. Clinical and NCS criteria were compared between (a) AMAN and AIDP and (b) two subgroups of children with AMAN-those who achieved early (within 60 d) versus delayed (i.e., after 60 d) walking.

RESULTS

Fifty-seven children were initially enrolled, first NCS showed inexcitable nerves in 10, AMAN in 29, acute motor-sensory axonal neuropathy (AMSAN) in 3, AIDP in 13, and 2 were normal. Subsequent NCS showed AMAN in 37, AIDP in 15, AMSAN in 3 patients. There were no deaths, 16 required ventilation. Follow-up till independent walking, was available for 40 patients. AMAN was associated with faster progression, greater peak disability, prolonged hospital stay, and delayed walking (p < 0.05). Asymmetrical nerve involvement predicted prolonged hospital stay as well as delayed walking. In the AMAN group, prolonged ulnar F-wave latencies were significantly associated with delayed walking (p = 0.02).

CONCLUSION

Long term prognosis of pediatric GBS is generally satisfactory. AMAN, asymmetric involvement and prolonged ulnar F-wave latencies in children with AMAN were associated with delayed walking.

Neurologic Disorders Affecting the Foot and Ankle

The neurologic causes of foot and leg dysfunction are reviewed. Disorders causing foot and ankle pain, weakness, or other sensorimotor disturbances often cause difficulty with ambulation and prompt patients to seek medical evaluation. Physical signs and symptoms along with targeted diagnostic testing are needed to come to the correct diagnosis and treatment plan. An overview of peripheral nerve, muscle, and central nervous system disorders affecting the foot and leg are discussed.

Association between serum low-density neutrophils and acute-onset and recurrent Guillain-Barré syndrome

BACKGROUND AND AIM

Guillain-Barré syndrome (GBS) is one of the most common causes of acute flaccid paralysis. A timely assessment of this disease condition and its treatments are of vital importance to patients diagnosed with GBS. The purpose of this study is to investigate the variation trend of neutrophils along with disease courses and assess the prognostic value of serum low-density neutrophils (LDNs) in the acute-onset and recurrence of GBS.

METHODS

A total of 176 GBS patients were recruited. Patients were evaluated with Medical Research Council (MRC) sum score and the Hughes Functional Grading Scale score upon admission. Peripheral blood samples were collected for routine testing. Flow cytometry analysis was performed to identify LDNs. All patients were followed up to collect disease condition data.

RESULTS

The total neutrophil ratios and counts were significantly higher in patients with acute-onset GBS compared to healthy controls (HCs). These counts/ratios decreased during remission and re-elevated in recurrent GBS patients. However, no correlation was observed between the total neutrophil counts/ratios and the MRC sum score. The LDNs collected from different GBS courses were identified using flow cytometry. The counts and ratios were significantly higher in acute-onset GBS and recurrent GBS compared to HCs and patients in remission. The LDN counts/ratios displayed a negative correlation with the MRC sum scores in acute-onset GBS and recurrent GBS.

CONCLUSION

Our findings suggest that LDN counts/ratios are positively correlated with the acute-onset and recurrence of GBS and its severity. Therefore, LDNs might serve as an accessible prognostic indicator for disease progression monitoring.

Severe Acute Motor Axonal Neuropathy associated with Influenza-A (H1N1) Infection and Prolonged Respiratory Failure - A Case Report

Acute Motor Axonal Neuropathy (AMAN) is an immune-mediated disorder of the peripheral nervous system, part of the spectrum of the Guillain-Barre syndrome (GBS). An infectious event most often triggers it reported a few weeks before the onset. The reported case is of a 56 years-old woman who developed acute motor axonal neuropathy three weeks after respiratory infection with influenza A virus subtype H1N1. Despite early treatment with plasmapheresis and intravenous immunoglobulins, the patient remained tetraplegic, mechanically ventilated for five months, with repetitive unsuccessful weaning trails. The probable cause was considered to be phrenic nerve palsy in the context of acute motor axonal neuropathy. This case highlights that acute motor axonal neuropathy is a severe and life-threatening form of Guillain-Barre syndrome associated with significant mortality and morbidity. Neurological and physical recovery strongly depend on the inter-professional effort in an intensive care unit and neurology professionals.

Severe Guillain-Barré syndrome associated with chronic hepatitis B: A case report and literature review

RATIONALE

Guillain-Barré syndrome (GBS) is a postinfectious autoimmune peripheral neuropathy characterized by acute paralysis of the limbs. Clinically, extrahepatic manifestations of neurologic involvement in chronic hepatitis B (CHB) are uncommon. Little attention has been paid to the relationship between GBS and CHB viral infection.

PATIENT CONCERNS

We presented a severe case of a 34-year-old man with general fatigue, anorexia, jaundice, numbness, and even muscle atrophy in the limbs, and respiratory failure during an acute exacerbation of CHB.

DIAGNOSES

Serological liver enzymes test confirmed an acute exacerbation of CHB. Nerve conduction studies revealed the features of acute motor and sensory axonal neuropathy combined with acute inflammatory demyelinating polyneuropathy, and cerebrospinal fluid analysis showed albuminocytologic dissociation. Clinical manifestations and the test results were consistent with a diagnosis of severe CHB-related GBS.

INTERVENTIONS

He was treated with mechanical ventilation, 2 courses of intravenous immunoglobulin, antichronic hepatitis B drugs therapy supplemented by hepatoprotection, acupuncture and rehabilitation.

OUTCOMES

After 29 days of hospitalization, his neurological condition improved. At a 6-month follow-up visit, he was able to walk with the support of another person.

LESSONS

The acute exacerbation of CHB may be a potential predisposing factor for the onset of GBS. This case is a reminder to clinicians that during the acute exacerbation of CHB, patients with neurological symptoms in the limbs should be considered for potential CHB-related GBS.

Re-evaluating the accuracy of optimized electrodiagnostic criteria in very early Guillain-Barré syndrome: a sequential study

Using recent optimized electrodiagnostic criteria sets, we aimed at verifying the accuracy of initial nerve conduction studies (NCS) in classic very early Guillain-Barré syndrome (VEGBS), ≤ 4 days after onset, compared with the results of serial NCS. This is a retrospective study based on unreported and consecutive VEGBS patients admitted to two university hospitals between 2015 and 2019. Each patient had serial NCS in at least four nerves. Initial NCS studies were done within 4 days after onset, and serial ones from days 20 to 94. Electrophysiological recordings were blinded evaluated by four of the authors, GBS subtype being established accordingly. Seven adult classic VEGBS patients were identified with a median age of 58 years. At first NCS, GBS subtyping was only possible in 1 case that exhibited an axonal pattern, the remaining patterns being equivocal in 3, and mixed (combining axonal and demyelinating criteria) in the remaining 3. Upon serial NSC there was a rather intricate evolution of electrophysiological GBS patterns, 3 of them being classified as axonal or demyelinating, and the remaining 4 as equivocal or mixed. NCS in VEGBS systematically allows detection of changes suggestive of peripheral neuropathy, though even after serial studies accurate GBS subtyping was only possible in 43% of cases. We provide new pathophysiological insights for better understanding of the observed electrophysiological changes.

Epidemiological and clinical aspects of Guillain-Barré syndrome and its variants

BACKGROUND

Guillain-Barré syndrome (GBS), an acute polyradiculoneuropathy that occurs because of an abnormal inflammatory response in the peripheral nervous system, is clinically characterized by acute flaccid paresis and areflexia with or without sensory symptoms. This syndrome can lead to disabling or even life-threatening sequelae.

OBJECTIVE

This study aimed to present the clinical and epidemiological aspects of GBS in patients admitted to a tertiary-level hospital in the Federal District between January 2013 and June 2019.

METHODS

In this observational, cross-sectional and retrospective study, medical records of patients diagnosed with acute inflammatory demyelinating polyradiculoneuropathy, acute motor axonal neuropathy or acute axonal motor-sensitive neuropathy based on electromyographic findings were included, and clinical data were collected retrospectively.

RESULTS

A total of 100 patients (63 males and 37 females; ratio, 1.7:1) aged 2-86 years (mean, 36.4 years) were included. The mean annual incidence rate of GBS was 0.54 cases/100,000 inhabitants, with 52 and 49% of the cases occurring between October and March (rainy season) and between April and September (dry season), respectively. The proportions of patients showing each GBS variant were as follows: demyelinating forms, 57%; axonal forms, 39%; and undetermined, 4%. The mean duration of hospitalization was 8-15 days for most patients (38%). During hospitalization, 14% of the patients required mechanical ventilation and 20% experienced infectious complications.

CONCLUSION

The findings indicate that there was an increase in the incidence of GBS during the rainy season. Moreover, we did not observe the typical bimodal distribution regarding age at onset.

Acute motor axonal neuropathy after ipilimumab and nivolumab treatment in melanoma brain metastases: A case report and review of the literature

The use of immune checkpoint inhibitors including ipilimumab and nivolumab has expanded for several tumors including melanoma brain metastasis. These have resulted in a growing spectrum of neurologic immune-related adverse events, including ones that are rare and difficult to diagnose and treat. Here, we present a patient with melanoma brain metastasis who was treated with immune checkpoint inhibitors and developed an Acute Motor Axonal Neuropathy. To our knowledge, this is the first case of Acute Motor Axonal Neuropathy as an immune-related adverse event associated with combination treatment of ipilimumab and nivolumab, who was successfully treated. A 28-year-old woman with metastatic BRAF V600E melanoma developed melanoma brain metastasis and was enrolled on Checkmate 204, a Phase 2 clinical trial using ipilimumab (3 mg/kg intravenous) and nivolumab (1 mg/kg intravenous) every 3 weeks for four cycles, followed by monotherapy with nivolumab (240 mg intravenous) every 2 weeks. A few days after Cycle 2 of ipilimumab and nivolumab, she developed a pure motor axonal neuropathy consistent with Acute Motor Axonal Neuropathy. She was treated with several immunosuppressive treatments including high dose methylprednisolone, immune globulin, and infliximab, and her motor neuropathy eventually improved several months after onset of symptoms. Unfortunately, she had progression of her systemic disease and died several months later. This is the first case reported of Acute Motor Axonal Neuropathy associated with ipilimumab and nivolumab, successfully treated with immune-suppressive therapy. As the field of immunotherapy expands with the increasing use of the immune checkpoint inhibitors, it is critical to increase our knowledge and understanding of the neurologic immune-related adverse events associated with immune checkpoint inhibitors. This includes the spectrum of rare neurologic immune-related adverse events, which can be quite difficult to recognize and treat. Early consultations with neurology may expedite a diagnosis and treatment plan in patients with unexplained weakness receiving immune checkpoint inhibitor therapy.

Toward a machine learning model for a primary diagnosis of Guillain-Barré syndrome subtypes

Guillain-Barré Syndrome (GBS) is a neurological disorder affecting people of any age and sex, mainly damaging the peripheral nervous system. GBS is divided into several subtypes, in which only four are the most common, demanding different treatments. Identifying the subtype is an expensive and time-consuming task. Early GBS detection is crucial to save the patient's life and not aggravate the disease. This work aims to provide a primary screening tool for GBS subtypes fast and efficiently without complementary invasive methods, based only on clinical variables prospected in consultation, taken from clinical history, and based on risk factors. We conducted experiments with four classifiers with different approaches, five different filters for feature selection, six wrappers, and One versus All (OvA) classification. For the experiments, we used a data set that includes 129 records of Mexican patients and 26 clinical representative variables. Random Forest filter obtained the best results in each classifier for the diagnosis of the four subtypes, in the same way, this filter with the SVM classifier achieved the best result (0.6840). OvA with SVM classifier reached a balanced accuracy of 0.8884 for the Miller-Fisher (MF) subtype.

Spectrum of Acute Neuropathy Associated With Covid-19: A Clinical and Electrophysiological Study of 13 Patients From a Single Center

OBJECTIVES

To analyze clinical and nerve conduction patterns in patients with acute neuropathy, preceded by or concomitantly having Covid-19 disease (Acute neuropathy associated with Covid-19 or ANAC 19).

METHODS

A retrospective analysis of clinical details, laboratory evaluation and electrophysiological parameters in patients with ANAC 19 was performed. These data were compared with non-Covid Guillain-Barre syndrome (GBS) described in literature and also with patients with acute neuropathy without Covid-19 who had presented to the center during the study period.

RESULTS

Records of 13 patients with ANAC 19 were reviewed. Most patients clinically had paraparesis, and electrophysiologically showed demyelinating neuropathy. Peroneal and sural nerves were the most frequently abnormal motor and sensory nerves, respectively. A proportion of patients showed a peroneal velocity-sparing pattern. Higher incidence of paraparesis and encephalopathy differentiated ANAC 19 from non-Covid GBS.

CONCLUSIONS

ANAC 19 had a comparable electrophysiological profile to non-Covid GBS; however, it had a distinct clinical presentation.

Case Report: Guillain-Barré Syndrome Associated With COVID-19

Guillain–Barré syndrome (GBS) is a potentially fatal, immune-mediated disease of the peripheral nervous system that is usually triggered by infection. Only a small number of cases of GBS associated with COVID-19 infection have been published. We report here five patients with GBS admitted to the Neurology, Psychiatry, and Neurosurgery Hospital, Assiut University/Egypt from July 1 to November 20, 2020. Three of the five patients were positive for SARS-CoV-2 following polymerase chain reaction (PCR) of nasopharyngeal swabs on day of admission and another one had a high level of IgM and IgG; all had bilateral ground-glass opacities with consolidation on CT chest scan (GGO) and lymphopenia. All patients presented with two or more of the following: fever, cough, malaise, vomiting, and diarrhea with variable duration. However, there were some peculiarities in the clinical presentation. First, there were only 3 to 14 days between the onset of COVID-19 symptoms and the first symptoms of GBS, which developed into flaccid areflexic quadriplegia with glove and stocking hypoesthesia. The second peculiarity was that three of the cases had cranial nerve involvement, suggesting that there may be a high incidence of cranial involvement in SARS-CoV-2-associated GBS. Other peculiarities occurred. Case 2 presented with a cerebellar hemorrhage before symptoms of COVID-19 and had a cardiac attack with elevated cardiac enzymes following onset of GBS symptoms. Case 5 was also unusual in that the onset began with bilateral facial palsy, which preceded the sensory and motor manifestations of GBS (descending course). Neurophysiological studies showed evidence of sensorimotor demyelinating polyradiculoneuropathy, suggesting acute inflammatory polyneuropathy (AIDP) in all patients. Three patients received plasmapheresis. All of them had either full recovery or partial recovery. Possible pathophysiological links between GBS and COVID-19 are discussed.

Electrophysiological characteristics of patients with nitrous oxide abuse

Objective: In the young generations with nitrous oxide abuse (N₂O), featured electrophysiological response of the peripheral neuropathy caused by nitrous oxide remains to be defined.Methods: Patients with nitrous oxide abuse (20 cases), two variants of Guillain-Barré syndrome (GBS), that is, acute inflammatory demyelinating polyradiculoneuropathy (GBS-AIDP, 19 cases) and acute motor axonal neuropathy (GBS-AMAN, 18 cases), as well as diabetic peripheral neuropathy (DPN, 20 cases) were enrolled into this study. Electrophysiological parameters including distal motor latency (DML), motor nerve conduction velocity (MNCV), sensory nerve conduction velocity (SNCV), amplitudes of compound muscle action potential (CMAP), and sensory nerve action potential (SNAP) were measured and analyzed by comparing the parameters between the aforementioned patients groups as well as normal control group (20 subjects).Results: Compared to normal control subjects, patients with nitrous oxide abuse showed prolonged DML, slower MNCV and SNCV in the limbs, lower amplitudes of CMAP in the median, tibial and peroneal nerves, and lower SNAP in median and ulnar nerves. Abnormalities of MNCV and amplitudes of CMAP in the lower limbs were significantly higher than that in the upper limbs . Abnormal electrophysiological features of patients with nitrous oxide abuse were dramatically different from those in GBS-AIDP or DPN patients, but similar to those in GBS-AMAN patients.Conclusions: Nitrous oxide abuse could cause abnormal electrophysiological response in the limbs. Some of the parameters (DML, MNCV, SNCV, CMAP and SNAP) appeared significantly different between the patients with nitrous oxide abuse, GBS with AIDP or AMAN, and DPN patients.Significance: Electrophysiological examination could be considered as an important supporting factor in differential diagnosis for nitrous oxide abuse, GBS with AIDP or AMAN, and DPN.

Acute motor and sensory axonal neuropathy in association with primary Sjögren's syndrome: a case report

Background

Primary Sjögren’s syndrome is a chronic, autoimmune, connective tissue disorder that results from the infiltration of exocrine glands, especially the lacrimal and salivary glands, by autoantibodies. Patients with Sjögren’s syndrome commonly present with dry eyes (xerophthalmia) and dry mouth (xerostomia). However, the clinical manifestations of Sjögren’s syndrome can be complicated and variable due to involvement of extraglandular organ systems, such as the nervous system. The neurological manifestations of this disorder often precede those of other exocrine gland symptoms. Hence, early diagnosis of Sjögren’s syndrome remains a challenge.

Case presentation

We report the case of a 63-year-old woman with primary Sjögren’s syndrome who presented with acute motor and sensory axonal neuropathy (AMSAN). Treatment with glucocorticoids and immunosuppressants partially improved her muscle weakness and paresthesia.

Conclusions

This case demonstrates the importance of early recognition and diagnosis of AMSAN in association with primary Sjögren’s syndrome to achieve a favorable clinical outcome. Primary Sjögren’s syndrome may be underdiagnosed because of vague symptoms of the sicca complex. Comprehensive immunological testing to evaluate this condition may be performed in patients presenting with variants of Guillain-Barré syndrome.

Acute Axonal Motor Neuropathy With Completely Reversible Conduction Failure-Is It Really Axonal?

ABSTRACT

We present the case of a 24-year-old man with a 3-day history of limb weakness and flaccid tetraparesis, hyporreflexia, and gait difficulties (Hughes grade 3) in the examination. Electromyography at presentation revealed severe amplitude reduction in distal compound muscle action potentials of several nerves without features of demyelination, fulfilling electrodiagnostic criteria for acute axonal motor neuropathy. The patient was treated with immunoglobulin and recovered completely 21 days after symptom onset. Electromyography at this timepoint showed normalization of compound muscle action potentials without increased temporal dispersion. The electroclinical recovery profile in this patient is consistent with reversible conduction failure in distal nerve segments in detriment of axonal degeneration. Thus, it is an "axonal motor neuropathy" where axonopathy is unlikely, giving strength to the concept of "nodopathies/paranodopathies."

Case Report: Acute Bulbar Palsy Plus Syndrome: A Guillain-Barré Syndrome Variant More Prone to Be a Subtype Than Overlap of Distinct Subtypes

Objective: Acute bulbar palsy plus (ABPp) syndrome is a rare regional variant of Guillain-Barré syndrome (GBS) characterized by acute bulbar palsy combined with other cranial symptoms or ataxia without limb and neck weakness. We aim to investigate characteristics of ABPp syndrome and analyze its nosological position within the GBS spectrum.

Methods: A patient with ABPp syndrome was reported, and previous case reports of patients who met the criteria for ABPp syndrome from the literature were reviewed.

Results: A total of 28 patients were included in our study. Median age was 32 years. Most of the patients (78.6%) were from Asia, and 75.0% had preceding infection. The main accompanying symptoms were ophthalmoplegia (85.7%), facial palsy (60.7%), and ataxia (50.0%). There existed asymmetric weakness in the form of unilateral facial palsy (32.1%) and ptosis (3.6%). Approximately half of the patients had albuminocytological dissociation. All the tested patients were seropositive for antiganglioside antibodies, of which the two most common were immunoglobulin G (IgG) anti-GT1a (77.3%) and anti-GQ1b (59.1%) antibodies. Over one-third of the patients who underwent electrophysiological assessment showed subclinical neuropathy beyond cranial nerves. The outcome was generally favorable as 89.3% of patients made full recovery within 5 months.

Conclusion: The hitherto largest case series of ABPp syndrome advances our understanding of this disease. Serologically, the presence of IgG anti-GT1a and anti-GQ1b antibodies predicts and contributes to the disease. Phenotypically, ABPp syndrome is more prone to be a separate subtype of GBS than overlap of distinct subtypes and has the potential to complement current diagnostic framework of GBS.

Nodal conduction block: A unifying concept

A newly introduced term, "axonal conduction block," brought a confusion in the electrodiagnostic diagnosis of Guillain-Barrè syndrome (GBS). I am proposing the term "nodal conduction block" for "axonal conduction block." This unifying concept of nodal conduction block will accommodate both the traditional concept of demyelination as well as the new concept of nodopathy in the "axonal form of GBS,", making the practice of electrodiagnosis much easier.

A 44-Year-Old Hispanic Man with Loss of Taste and Bilateral Facial Weakness Diagnosed with Guillain-Barré Syndrome and Bell's Palsy Associated with SARS-CoV-2 Infection Treated with Intravenous Immunoglobulin

BACKGROUND This case report is of a patient who presented with loss of taste and facial weakness and was diagnosed with Guillain-Barre syndrome (GBS) and Bell's palsy, associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. GBS is a neurological emergency defined as acute inflammatory demyelinating polyneuropathy. The patient responded to intravenous immunoglobulin (IVIG) treatment. CASE REPORT We present the case of a 44-year-old Hispanic man who came for evaluation of bilateral facial weakness and lack of taste sensation. He had lower motor neuron facial weakness. His head computed tomography and brain magnetic resonance imaging scans did not show any pathological abnormalities. He tested positive for SARS-CoV-2 by a nasopharyngeal swab reverse transcription polymerase chain reaction (RT-PCR) test. Cerebrospinal fluid (CSF) analysis via lumbar puncture revealed elevated protein levels, no leukocytes, and a negative Gram stain. The CSF RT-PCR test for SARS-CoV-2 was negative. PCR tests of the CSF for other viral infections were negative. A diagnosis of GBS was made, and he was treated successfully with IVIG. After the fourth dose of IVIG, the patient was able to close his eyes, frown, show his teeth, and smile. CONCLUSIONS Our case is rare because the patient did not present with lower extremity weakness, but only with bilateral Bell's palsy. Physicians should be aware of GBS because it is a neurological emergency for which COVID-19 can be a risk factor. Early diagnosis and treatment of GBS can prevent neurological disability.

The prognostic value of demyelinating electrophysiologic findings and cerebrospinal fluid protein levels in acute inflammatory demyelinating polyneuropathy

BACKGROUND

Guillain-Barre syndrome is an acute immune-mediated polyneuropathy characterized by rapidly evolving symptoms and disability. Cerebrospinal fluid analysis and electrophysiological studies are crucial in the diagnosis of this syndrome.

OBJECTIVE

To evaluate the prognostic value of the type and number of demyelinating findings and cerebrospinal fluid protein levels in patients with acute inflammatory demyelinating polyneuropathy.

METHODS

We retrospectively analyzed electrophysiological data and cerebrospinal fluid of 67 consecutive patients with acute inflammatory demyelinating polyneuropathy from Istanbul, Turkey (2011-2019) studied ≤ 24 hours post-onset.

RESULTS

The patients who met a higher number of demyelinating criteria had increased disability scores in the first day and first month, and higher cerebrospinal fluid protein levels were correlated with worse prognosis both on the first day and the first month. However, the disability scores did not correlate with any single specific criterion, and no significant correlation was found between the number of satisfied criteria and cerebrospinal fluid protein levels.

CONCLUSIONS

The number of demyelinating criteria that are met and high cerebrospinal fluid protein levels at the disease onset may be valuable prognostic markers. More systematic studies conducted with serial nerve conduction studies are required to highlight the roles of the suggested criteria in clinical practice.