Guillain–Barré Syndrome and Swallowing Dysfunction:

Diagnostic odyssey of Guillain-Barré syndrome in children

BACKGROUND AND OBJECTIVES

A gap exists between difficulty in diagnosis and importance of early recognition and intervention in pediatric Guillain-Barré syndrome (GBS). Therefore, this study aimed to establish a diagnostic odyssey plot that allows "at-a-glance" overview of the diagnostic odyssey of GBS in children, including overall diagnostic delay, physician-related and patient-related diagnostic delays, and length and frequency of diagnostic errors.

METHODS

In this single-center retrospective cohort study, standardized data were obtained from children with GBS from 2003 to 2020. Overall diagnostic delay (time between symptom onset and diagnosis), physician-related diagnostic delay (time between the first medical visit and diagnosis), and patient-related diagnostic delay (time between symptom onset and the first medical visit) were analyzed.

RESULTS

The study examined a total of 21 patients (11 men, median age 4.5 years). Overall, there were 40 misdiagnoses among 17 patients, while four were diagnosed correctly at the first visit. The overall diagnostic delay was 9 days [interquartile range (IQR), 6-17 days]. Physician-related diagnostic delay, but not patient-related diagnostic delay, was correlated with the overall diagnostic delay. Patients in the late-diagnosed group were more frequently misdiagnosed during their diagnostic odyssey than patients in the other groups. Risk factors associated with diagnostic delay included delayed onset of weakness and sensory deficits, absence of swallowing problems, and misdiagnosis as orthopedic disorders or viral infections.

DISCUSSION

A unique diagnostic odyssey exists in pedaitric GBS. Several clinical risk factors were associated with the diagnostic delay.

Predictors of discharge to home/community following inpatient-rehabilitation in a US national sample of Guillain-Barre-Syndrome patients

BACKGROUND

Guillain-Barre-Syndrome (GBS), an autoimmune polyneuropathy causing acute flaccid paralysis, is a rare condition with1-2 cases per 100,000 annually (approximately 5000 cases/year) in the United States (US). There is a paucity of published data regarding patient outcomes in association with discharge destinations following inpatient-rehabilitation (IR) in this patient population, thus this study.

OBJECTIVES

To analyze IR efficacy, and possible predictors of discharge to home/community in a US-national-sample of GBS patients.

METHODS

Retrospective-observational-cohort study of 1304 GBS patients admitted to IR comparing discharge disposition destinations (community/home, skilled-nursing-facility [SNF], or return to acute-care) by demographic (age, gender) and clinical variables (length-of-stay [LOS], case-mix-index [CMI], and Functional-Independence-Measure [FIM] score changes). Multinomial-logistic-regression and discriminant-function-analysis were performed to determine model fit in predicting discharge destination.

RESULTS

81.8% were discharged to home/community- average LOS 19-days, total-FIM-gain 43.2; 9.8% discharged to SNFs- average LOS 27.5-days, total-FIM-gain 27.2; and 8.4% discharged to acute-care- average LOS 15.4-days and total-FIM-gain 16.5, (F = 176, p < .001). Stepwise-linear-regression for prediction of community discharge showed change in FIM-Bed/chair/wheelchair-Transfers was the most significant predictor (Wald = 42.2; p < .001), followed by CMI (Wald = 26.9; p < .001), change in FIM-walking/wheelchair (Wald = 14.9; p < .001), and age (Wald = 9.5; p < .002). Using discriminant-function-analysis to test model validity for predicting discharge disposition, FIM-change for Bed/chair/wheelchair Transfers, Walking, and Self-Care as predictors resulted in a classification rate of 78.1%, 92% of variance explained, and Eigenvalue of .53 (p < .001).

CONCLUSIONS

Total-FIM scores improved in all groups, and most patients were discharged to home/community suggesting IR efficacy. The ability to transfer bed/chair/wheelchair was the most important predictive factor associated with discharge destination.

Early Approach Towards Atypical Guillain-Barré Syndrome: A Physiotherapy Perspective in a Case Report

Guillain-Barré syndrome (GBS) is acute, ascending, immune-mediated, monophasic polyneuropathy, which manifests itself as a lower motor neuron lesion, which occurs mostly after a prior infection. It is autoimmune in origin and has an impact on the peripheral nervous system. GBS is usually not linked to an autoimmune or other systemic condition and is most frequently a post-infectious disorder that affects healthy patients. The symptoms of GBS, an acute immune-mediated polyradiculoneuropathy, include symmetrical limb weakness that worsens quickly and hypo- or areflexia. There may also be sensory complaints, involvement of cranial and autonomic nerve fibres, and frequent pain that will appear before weakening. Weakness, sensory loss, weariness, and discomfort are the most typical remaining deficiencies in an atypical variant of GBS. This case also describes the variant of atypical GBS. A 10-year-old girl was referred to the hospital with complaints of difficulty in swallowing, drooling of saliva, weakness of left upper and bilateral lower limbs, and fever for 10 days. There was no past history of travelling or infection. At the time of admission, the patient was on oxygen support for breathing and she was transferred to ICU immediately. Investigations were done such as a nerve conduction velocity test and complete blood count. Neuro-physiotherapy of the patient was started after 35 days of hospitalisation. With proper rehabilitation, the patient was able to gain strength and the ability to swallow food. The patient was able to resume her academic career.

Autoimmune Neurogenic Dysphagia

Autoimmune neurogenic dysphagia refers to manifestation of dysphagia due to autoimmune diseases affecting muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. Dysphagia is either part of the evolving clinical symptomatology of an underlying neurological autoimmunity or occurs as a sole manifestation, acutely or insidiously. This opinion article reviews the autoimmune neurological causes of dysphagia, highlights clinical clues and laboratory testing that facilitate early diagnosis, especially when dysphagia is the presenting symptom, and outlines the most effective immunotherapeutic approaches. Dysphagia is common in inflammatory myopathies, most prominently in inclusion body myositis, and is frequent in myasthenia gravis, occurring early in bulbar-onset disease or during the course of progressive, generalized disease. Acute-onset dysphagia is often seen in Guillain–Barre syndrome variants and slowly progressive dysphagia in paraneoplastic neuropathies highlighted by the presence of specific autoantibodies. The most common causes of CNS autoimmune dysphagia are demyelinating and inflammatory lesions in the brainstem, occurring in patients with multiple sclerosis and neuromyelitis optica spectrum disorders. Less common, but often overlooked, is dysphagia in stiff-person syndrome especially in conjunction with cerebellar ataxia and high anti-GAD autoantibodies, and in gastrointestinal dysmotility syndromes associated with autoantibodies against the ganglionic acetyl-choline receptor. In the setting of many neurological autoimmunities, acute-onset or progressive dysphagia is a potentially treatable condition, requiring increased awareness for prompt diagnosis and early immunotherapy initiation.

Ti.: "High" vagus nerve lesions in varicella Zoster infection

“High” vagus nerve lesions are rare and refer to the region of the nerve from the jugular foramen through the branching of the auricular (Arnold's branch) and the pharyngeal branch. Rapid onset of vagus nerve palsy is observed predominantly in trauma, and rarely in inflammation. An insidious onset points to a neoplastic cause.

The acute “high” vagus nerve lesion is characterized by a unilateral paralysis of the recurrent laryngeal nerve, an incomplete paresis of the soft palate and a transient inability to swallow.

This is a case description of a 79-year-old woman who presented with painful swelling of the left ear and occipital headache, followed by inability to swallow for 3 weeks. A markedly elevated Varicella Zoster titer suggested a herpes virus infection.

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Cranial nerve

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Vagus nerve

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High vagus nerve

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acute swallowing disorder

Mechanical ventilation in Guillain-Barré syndrome

Introduction: Up to 30% of patients with Guillain-Barré syndrome (GBS) develop respiratory failure requiring intensive care unit (ICU) admission and mechanical ventilation. Progressive weakness of the respiratory muscles is the leading cause of acute respiratory distress and respiratory failure with hypoxia and/or hypercarbia. Bulbar weakness may compromise airway patency and predispose patients to aspiration pneumonia. Areas covered: Clinical questions related to the use of mechanical ventilation include but are not limited to: When to start? Invasive or noninvasive? When to wean from mechanical ventilation? When to perform tracheostomy? How to manage complications of GBS in the ICU including nosocomial infection, ventilator-associated pneumonia, and ICU-acquired weakness? In this narrative review, the authors summarize the up-to-date knowledge of the incidence, pathophysiology, evaluation, and general management of respiratory failure in GBS. Expert opinion: Respiratory failure in GBS merits more attention from caregivers. Emergency intubation may lead to life-threatening complications. Appropriate methods and time point of intubation and weaning, an early tracheostomy, and predictive prophylaxis of complications benefit patients' long-term prognosis.

Therapy-resistant dysphagia successfully treated using pharyngeal electrical stimulation in a patient with the pharyngeal-cervical-brachial variant of the Guillain-Barré syndrome

Pharyngeal electrical stimulation (PES) is a novel treatment for oropharyngeal dysphagia resulting from neurogenic causes such as stroke, prolonged intubation, tracheostomy, or multiple sclerosis, and may be effective in other medical conditions such as Guillain-Barré syndrome (GBS). A 74-year-old male patient with a pharyngeal-cervical-brachial (PCB) variant of GBS, who had been tracheotomised due to severe and persistent swallowing difficulties (dysphagia) unresponsive to traditional speech and language therapy, received PES therapy as a final treatment option. Swallow performance evaluated before and after PES using fibreoptic endoscopic evaluation of swallowing, videofluoroscopy and clinical bedside assessment, showed significant improvement in swallowing resulting in safe tracheostomy decannulation 18 days after PES.

In PCB GBS, we present the potential benefit of PES for the treatment of persistent dysphagia and faster tracheostomy decannulation. PES was safe and may be beneficial in other neurologic disorders, where traditional dysphagia therapies have proved unsuccessful.

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Pharyngeal electrical stimulation (PES) led to a rapid improvement of severe dysphagia in a patient with pharyngeal-cervical-brachial variant of Guillain-Barré syndrome.

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PES is an approved treatment for neurogenic dysphagia, is easy-to-use and is safe.

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PES is an efficient and innovative adjunctive to traditional speech and language therapies available for dysphagia.

Intubation, tracheostomy, and decannulation in patients with Guillain-Barré-syndrome-does dysphagia matter?

INTRODUCTION

Although patients with Guillain-Barré syndrome frequently require orotracheal intubation and tracheostomy, the incidence and relevance of neurogenic dysphagia prior to intubation and risk factors for prolonged requirement for a tracheal cannula have not yet been identified.

METHODS

Retrospective analysis of the medical records of 88 patients was performed. Clinical characteristics were compared between intubated and nonintubated patients and between immediately decannulated and not immediately decannulated patients.

RESULTS

Thirty-five (39.7%) patients required tracheostomy. Neuromuscular weakness and related respiratory insufficiency were the main reasons for intubation. In the subgroup of tracheotomized patients, immediate decannulation after completed respiratory weaning was possible in 14 (40%) patients. The severity of dysphagia, in particular pharyngolaryngeal hypesthesia, was related to the length of cannulation.

DISCUSSION

Respiratory muscle weakness is the main reason for intubation, whereas neurogenic dysphagia is the main risk factor for persisting cannulation. Dysphagia after weaning is most frequently characterized by severe laryngeal sensory deficit. Muscle Nerve 59:194-200, 2019.