Guillain-Barré syndrome with severe persistent disability: relationship to hyperacute Guillain-Barré syndrome

Hyperacute and Fulminant Guillain-Barré Syndrome Requiring Emergent Intubation

Guillain-Barré syndrome (GBS) is an autoimmune-mediated acute polyneuropathy that can progress to life-threatening respiratory failure. The diagnosis and treatment of this pathology are complicated by the rarity of the disease and diversity in clinical presentation due to rarer, more dangerous subtypes of GBS. Understanding the time course of progression from onset to nadir of neurological deficits, maintaining a high index of suspicion, and close airway monitoring are essential in rapid diagnosis, securing the airway, and treatment.

Atypical Guillain-Barre Syndrome With a Sensory Level and Hyper-Acute Presentation: A Case Report

A 46-year-old man with a prior history of cervical spondylosis and myelopathy needing cervical spinal surgery three years back presented to the emergency department with acute onset areflexic flaccid weakness of both lower extremities, with a sensory level at T10. Magnetic resonance imaging studies (MRI) of the cervical, thoracic, and lumbar spine ruled out significant cord compression, spinal cord ischemia, spinal shock, or findings to suggest transverse myelitis. CSF analysis showed normal albumin and protein; however, with the features of paraplegia with flaccidity, areflexia, absence of bowel and bladder symptoms, and MRI ruling out other possibilities, a diagnosis of Guillain-Barre syndrome (GBS) was made. The patient was treated with intravenous immunoglobulin (IVIG) and showed a clinical response, with improvement in strength in both lower extremities. This case is rare and unique, as it exhibits atypical features for a GBS case, including a sensory level and hyper-acute presentation, with the onset of weakness to a nadir within an hour. This case highlights the importance of awareness of such atypical GBS presentations so that the diagnosis is not missed and is appropriately managed for favorable patient outcomes.

Risk Prediction Models for Early ICU Admission in Patients With Autoimmune Encephalitis: Integrating Scale-Based Assessments of the Disease Severity

Background

In patients with autoimmune encephalitis (AE), the prediction of progression to a critically ill status is challenging but essential. However, there is currently no standard prediction model that comprehensively integrates the disease severity and other clinical features. The clinical assessment scale in autoimmune encephalitis (CASE) and the modified Rankin Scale (mRS) have both been applied for evaluating the severity of AE. Here, by combining the two scales and other clinical characteristics, we aimed to investigate risk factors and construct prediction models for early critical care needs of AE patients.

Methods

Definite and probable AE patients who were admitted to the neurology department of Tongji Hospital between 2013 and 2021 were consecutively enrolled. The CASE and mRS scores were used to evaluate the overall symptom severity at the time of hospital admission. Using logistic regression analysis, we analyzed the association between the total scores of the two scales and critical illness individually and then we evaluated this association in combination with other clinical features to predict early intensive care unit (ICU) admission. Finally, we constructed four prediction models and compared their performances.

Results

Of 234 patients enrolled, forty developed critical illness and were early admitted to the ICU (within 14 days of hospitalization). Four prediction models were generated; the models were named CASE, CASE-plus (CASE + prodromal symptoms + elevated fasting blood glucose + elevated cerebrospinal fluid (CSF) white blood cell (WBC) count), mRS and mRS-plus (mRS + prodromal symptoms + abnormal EEG results + elevated fasting blood glucose + elevated CSF WBC count) and had areas under the ROC curve of 0.850, 0.897, 0.695 and 0.833, respectively. All four models had good calibrations. In general, the models containing “CASE” performed better than those including “mRS”, and the CASE-plus model demonstrated the best performance.

Conclusion

Overall, the symptom severity at hospital admission, as defined by CASE or mRS, could predict early ICU admission, especially when assessed by CASE. Adding other clinical findings, such as prodromal symptoms, an increased fasting blood glucose level and an increased CSF WBC count, could improve the predictive efficacy.

Rate of progression of Guillain-Barré syndrome is not associated with the short-term outcome of the disease

INTRODUCTION

There are no many data on association between progression rate of Guillain-Barré syndrome (GBS) and disease outcome.

AIM

The aim of our study was to analyze short-term outcome of GBS in relation to the rate of disease progression.

METHODS

Our retrospective study included patients diagnosed with GBS in seven tertiary healthcare centers from 2009 to 2014. According to the rate of disease progression from onset of symptoms to the nadir, patients were divided in three groups: rapid-onset GBS (nadir reached in maximum 48 h), gradual-onset (nadir reached in three to 14 days), and slow-onset (nadir in 15 to 28 days). GBS disability scale (GDS) was used to assess functional disability at nadir and on discharge.

RESULTS

Among 380 patients included in the study, 24 (6.3%) patients had rapid-onset, 274 (72.1%) gradual-onset, and 82 (21.6%) slow-onset GBS. Time from the onset of the disease to the hospital admission was much shorter in faster-onset forms (3.0 ± 4.1 days in rapid-onset vs. 6.8 ± 9.5 days in gradual-onset and 21.0 ± 9.6 days in slow-onset GBS, p < 0.01). Preceding events were less commonly identified in slow-onset forms. Patients with rapid-onset GBS were more likely to have axonal variants (p < 0.05). All three groups of patients were treated in a similar way, and there were no differences in GDS score at nadir (p > 0.05) and on discharge (p > 0.05) and no differences in the duration of hospital stay.

CONCLUSION

Faster progression of GBS does not imply a poorer short-term functional outcome of the disease.

Event-related potentials in patients with total locked-in state due to fulminant Guillain-Barré syndrome

A series of electrophysiological investigations were performed over a 6-month period in two patients affected by fulminant Guillain-Barré polyradiculoneuropathy, who developed an ascending paralysis leading, within 72 h, to flaccid quadriplegia, internal and external ophthalmoplegia, absence of all brainstem reflexes and no respiratory effort: the clinical state resembled brain death. Brain CTs were normal and spinal fluid examination revealed albuminocytological dissociation. All motor nerves tested were unexcitable, whereas sensory responses were markedly abnormal but present. Sequential EEG recordings revealed normal, partially reactive alpha rhythm in both patients. In one patient, normal auditory event-related potentials (ERPs: peak N1, P2, N2, P3, evoked in an 'oddball' paradigm) and CNV-like potentials could be recorded not earlier than the 20th day into the illness. In earlier recordings, N1 and P2 peaks as well as mismatch negativity (MMN) were present over the frontal and central scalp electrodes. This patient has now partially recovered motor functions and no cognitive defects are present, but he has little recollection of the events occurring in the first 2 weeks spent in the ICU, when he was completely paralyzed. The other patient generated normal N1 and P2 ERP peaks, but no N2, P3 and MMN were detected in a series of recordings. He died without having ever regained appropriate behavioral responses. The ERP abnormalities observed raise the matter of the origin of cognitive dysfunction in patients with severe and prolonged de-efferentation/de-afferentation. ERPs allow monitoring the level of alertness and attention and appear more specific than EEG in identifying a state of awareness in patients in which communication is severely impaired as a consequence of neurological disorders.

Fulminant Guillain-Barré syndrome with universal inexcitability of peripheral nerves: a clinicopathological study

The pathological basis of nerve inexcitability in Guillain-Barré syndrome has not been established with certainty. We report the clinicopathological findings in a 67-year-old patient with fulminant Guillain-Barré syndrome who died 18 days after onset. Three serial electrophysiological studies revealed nerve inexcitability. Antibodies to Campylobacter jejuni were present but there was no antiganglioside reactivity. Spinal root sections revealed extensive and almost pure macrophage-associated demyelination with occasional presence of T lymphocytes and neutrophil leukocytes. Conversely, in femoral, median, and sural nerves the outstanding lesion was axonal degeneration, with some denuded axons remaining. Unmyelinated fibers, posterior root ganglia, and dorsal columns were preserved. Endoneurial postcapillary venules showed plump endothelial cells with loss of their tight junctions. We conclude that both primary demyelination and axonal degeneration secondary to inflammation account for nerve inexcitability. Our findings lend support to the hypothesis of increased endoneurial pressure as the cause of wallerian degeneration in nerve trunks.

The long-term prognosis of Guillain-Barré syndrome. Evaluation of prognostic factors including plasma exchange

Fifty-two patients with Guillain-Barré syndrome (GBS) were re-examined 1-14 years (median 7 years) after the initial onset of symptoms. At the follow-up 38 patients (73%) reported being completely symptom-free. Neurological examination revealed that 11 patients (21%) had motor and 16 patients (31%) had sensory signs, mainly distal in the lower limbs. One patient (2%) had cranial nerve signs. Fifteen patients (29%) had areflexia, generally of the ankle jerks. Severe pareses (high maximal disability grade), long duration of maximal symptoms and recovery were significantly associated with persistent disability. Age, sex, preceding infection, latency between infection and the onset of disease, weakness as an initial symptom, autonomic dysfunction, speed of progression, electro-physiological signs of axonal degeneration, cerebrospinal-fluid protein concentration and treatment with plasma exchange did not significantly influence the disability grade at follow-up.

Affinity of anti-GM1 antibodies in Guillain-Barré syndrome patients

In this study, we investigated the affinity of anti-GM1 IgG antibodies as well as their IgG subclass distribution in a series of 38 patients with Guillain-Barré syndrome. In 7 sera elevated titres of IgG anti-GM1 antibodies could be detected. With respect to affinity there were two distinct groups of anti-GM1 antibodies: one group was of high affinity and did not cross-react with other glycolipids; the other group was of low affinity and cross-reacted with asialo-GM1. IgG1 was the predominant and almost exclusive subclass of high affinity anti-GM1 antibodies. Axonal degeneration occurred significantly more frequently in patients with high affinity anti-GM1 antibodies than in patients without anti-GM1 antibodies or in patients with low affinity anti-GM1 antibodies. The presence of anti-Campylobacter jejuni antibodies was not associated with a specific electrophysiological pattern. The prognosis was not dependent on the detection of any of the antibodies, whereas axonal loss and ventilation were associated with a poor prognosis.

Campylobacter jejuni infection and Guillain-Barré syndrome

BACKGROUND

Although infection with Campylobacter jejuni is recognized as a common antecedent of the Guillain-Barré syndrome, the clinical and epidemiologic features of this association are not well understood.

METHODS

We performed a prospective case-control study in a cohort of patients with Guillain-Barré syndrome (96 patients) or Miller Fisher syndrome (7 patients) who were admitted to hospitals throughout England and Wales between November 1992 and April 1994. Bacteriologic and serologic techniques were used to diagnose preceding C. jejuni infection.

RESULTS

There was evidence of recent C. jejuni infection in 26 percent of the patients with Guillain-Barré or Miller Fisher syndrome, as compared with 2 percent of household controls and 1 percent of age-matched hospital controls (P < 0.001). Of the 27 patients with C. jejuni infection, 19 (70 percent) reported having had a diarrheal illness within 12 weeks before the onset of the neurologic illness. No specific serotypes were associated with Guillain-Barré syndrome. C. jejuni infection was slightly more common in men (P = 0.14) and was more likely to be associated with a pure motor syndrome and a slower recovery (P = 0.03). The patients with preceding C. jejuni infection were more likely to have acute axonal neuropathy or axonal degeneration in association with acute inflammatory demyelinating polyradiculoneuropathy, and they had greater disability after one year (P = 0.02). C. jejuni infection was significantly associated with a poor outcome even after correction for other factors associated with a poor prognosis.

CONCLUSIONS

Infection with C. jejuni often precedes the Guillain-Barré syndrome and is associated with axonal degeneration, slow recovery, and severe residual disability.