Increased incidence of Guillain-Barré syndrome after surgery

Guillain-Barré syndrome: A comprehensive review

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.

Superacute onset of Guillain-Barré syndrome after elective spinal surgery: A case report and literature review

RATIONALE

Guillain-Barré syndrome (GBS) epitomizes an acute peripheral neuropathy hallmarked by an autoimmune retort directed at the myelin sheath enwrapping peripheral nerves. While it is widely acknowledged that a majority of GBS patients boast a history of antecedent infections, the documentation of postoperative GBS occurrences is progressively mounting. Drawing upon an exhaustive compendium of recent case reports, the disease's inception spans a gamut from within 1 hour to 1.2 years.

PATIENT CONCERNS

At this juncture, we proffer a singular case: an instance involving a 51-year-old gentleman who underwent lumbar spine surgery, only to encounter immediate debilitation of limb and respiratory musculature.

DIAGNOSES

Post elimination of variables linked to anesthetic agents, encephalon, and spinal cord pathologies, a potent suspicion of superacute GBS onset emerged.

INTERVENTIONS

Subsequent to immunoglobulin therapy, plasmapheresis, and adjunctive support, the patient's ultimate demise became manifest.

OUTCOMES

No progress was found to date.

LESSONS

Given GBS's potential to instigate paralysis, respiratory collapse, and autonomic nervous system aberrations, alongside other pernicious sequelae, coupled with the exceptional rarity of the temporal onset in this particular instance, it undeniably proffers an imposing conundrum for anesthetists in the realm of differential diagnosis and therapeutic conduct. During the postoperative convalescence phase under anesthesia, should the patient evince deviant limb musculature vigor and compromised respiratory sinews, the prospect of GBS must not be consigned to oblivion. Precision in diagnosis conjoined with apt therapeutic measures could well be the harbinger of a divergent denouement for the afflicted patient.

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.

Locked in from fulminant GBS after lumbar spine surgery

Guillain-Barré syndrome (GBS) describes a neurological syndrome characterised by acute, areflexic paralysis, often preceded by an immune stimulating event such as infection or surgery. Spinal surgery as an inciting event is very uncommon with few reported cases. When paraparesis develops in close proximity of surgery, surgical complications should be considered, but if an asymptomatic clinical interval precedes a progressive ascending weakness this association weakens and may support an immunological mechanism. GBS after lumbar surgery is wholly unexpected and thus there are significant challenges in recognising and making the diagnosis. We report a case of fulminant GBS that progressed to loss of all motor function following elective lumbar spine surgery.

High risk and low prevalence diseases: Guillain-Barré syndrome

INTRODUCTION

Guillain-Barré syndrome (GBS) is a rare but serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of GBS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

GBS is a rare immune-mediated neurologic disorder with peripheral nerve injury. It most commonly presents weeks after a bacterial or viral infection, though there are a variety of associated inciting events. The diagnosis is challenging and often subtle, as only 25-30% of patients are diagnosed on their initial healthcare visit. Clinicians should consider GBS in patients with progressive ascending weakness involving the lower extremities associated with hyporeflexia, but the cranial nerves, respiratory system, and autonomic system may be involved. While the ED diagnosis should be based on clinical assessment, further evaluation includes laboratory testing, cerebrospinal fluid (CSF) analysis, and potentially neuroimaging. Not all patients demonstrate albumino-cytological dissociation on CSF testing. Several criteria exist to assist with diagnosis, including the National Institute of Neurological Disorders and Stroke criteria and the Brighton criteria. Management focuses first on assessment of the patient's hemodynamic and respiratory status, which may require emergent intervention. Significant fluctuations in heart rate and blood pressure may occur, and respiratory muscle weakness may result in the need for airway protection. Neurology consultation is recommended, and definitive treatment includes PLEX or IVIG.

CONCLUSIONS

An understanding of GBS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Current status of Guillain-Barré syndrome (GBS) in China: a 10-year comprehensive overview

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy; a disease involving the peripheral nervous system which is the most common cause of acute flaccid paralysis worldwide. So far, it is still lack of a comprehensive overview and understanding of the national epidemiological, clinical characteristics, and the risk factors of GBS in China, as well as differences between China and other countries and regions in these respects. With the global outbreak of the coronavirus disease 2019 (COVID-19), an epidemiological or phenotypic association between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection and GBS has attracted great attention. In this review, we outlined the current clinical data of GBS in China by retrieving literature, extracting and synthesizing the data of GBS in China from 2010 to 2021. Besides, we compared the characteristics of epidemiology, preceding events and clinical profiles of GBS between China and other countries and regions. Furthermore, in addition to conventional intravenous immunoglobulin (IVIG) and plasma exchange (PE) therapy, the potential therapeutic effects with novel medications in GBS, such as complement inhibitors, etc., have become the research focus in treatments. We found that epidemiological and clinical findings of GBS in China are approximately consistent with those in the International GBS Outcome Study (IGOS) cohort. We provided an overall picture of the present clinical status of GBS in China and summarized the global research progress of GBS, aiming to further understand the characteristics of GBS and improve the future work of GBS worldwide, especially in countries with the middle and low incomes.

European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome

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.

European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome

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.

Guillain-Barré syndrome after percutaneous coronary intervention and transcatheter aortic valve implantation

Guillain-Barré syndrome (GBS) usually develops after preceding infection, but cardiac surgery can also occasionally cause GBS. Currently, cardiac catheterizations have already become common therapeutic options for heart diseases, but there have been no reports of GBS occurrence after that. Herein, we present a rare case in which GBS occurred following catheterization. An 85-year-old-man with sudden onset chest pain was rushed to our hospital and diagnosed with ST-elevated myocardial infarction. He underwent emergent percutaneous coronary intervention (PCI) to left anterior descending artery, but he still had exertional chest pain. Echocardiography revealed severe aortic stenosis (AS) and our heart team considered AS was the cause of symptom and decided to perform and transcatheter aortic valve implantation (TAVI), 11 days after the PCI. However, 5 days after the TAVI procedure, he presented with symmetrical muscular weakness of extremities. Cranial magnetic resonance imaging showed no significant lesion. Based on several signs including albuminocytologic dissociation in cerebrospinal fluid examination, demyelinating polyneuropathy in nerve conduction study, positive anti-ganglioside antibody, and the lack of preceding infection, he was diagnosed with GBS triggered by cardiac catheterizations. We administered high-dose intravenous immunoglobulin therapy and his motor strength gradually improved, finally discharged with full motor strength after 7 months rehabilitation.

Learning objective

•Cardiac surgery has been already reported as a non-infectious risk factor of Guillain-Barré syndrome (GBS) in previous literatures, and cardiac catheterization such as percutaneous coronary intervention and transcatheter aortic valve implantation, which were relatively less invasive procedure, may be a potential risk factor for GBS occurrence as well.•If a patient complains of progressive, symmetrical neurological symptoms after cardiac catheterization, GBS should be considered as the possible cause, and nerve conduction study and cerebrospinal fluid examination may be helpful for the diagnosis.

Hospital-diagnosed morbidities and recent surgery as risk factors for developing Guillain-Barré syndrome

BACKGROUND AND PURPOSE

This study was undertaken to determine the association of hospital-diagnosed morbidity and recent surgery with risk of subsequent Guillain-Barré syndrome (GBS) development.

METHODS

We conducted a nationwide population-based case-control study of all patients with first-time hospital-diagnosed GBS in Denmark between 2004 and 2016 and 10 age-, sex-, and index date-matched population controls per case. Hospital-diagnosed morbidities included in the Charlson Comorbidity Index were assessed as GBS risk factors up to 10 years prior to the GBS index date. Incident major surgery was assessed within 5 months prior.

RESULTS

In the 13-year study period, there were 1086 incident GBS cases, whom we compared with 10,747 matched controls. Any pre-existing hospital-diagnosed morbidity was observed in 27.5% of GBS cases and 20.0% of matched controls, yielding an overall matched odds ratio (OR) of 1.6 (95% confidence interval [CI] = 1.4-1.9). The strongest associations were found for leukemia, lymphoma, diabetes, liver disease, myocardial infarction, congestive heart failure, and cerebrovascular disease, with 1.6- to 4.6-fold increased risks of subsequent GBS. GBS risk was strongest for morbidities newly diagnosed during the past 5 months (OR = 4.1, 95% CI = 3.0-5.6). Surgical procedures within 5 months prior were observed in 10.6% of cases and 5.1% of controls, resulting in a GBS OR of 2.2 (95% CI = 1.8-2.7). Risk of developing GBS was highest during the first month following surgery (OR = 3.7, 95% CI = 2.6-5.2).

CONCLUSIONS

In this large nationwide study, individuals with hospital-diagnosed morbidity and recent surgery had a considerably increased risk of GBS.

Guillain-Barre syndrome after myocardial infarction: a case report and literature review

BACKGROUND

Guillain-Barre syndrome after myocardial infarction occurs infrequently, and its occurrence following percutaneous coronary intervention is extremely rare. Due to the high mortality rate of myocardial infarction and the disability of Guillain-Barre syndrome, early identification of Guillain-Barre syndrome after myocardial infarction and early intervention can decrease the mortality rate, lead to early recovery, and provide a better outcome.

CASE PRESENTATION

Herein, we reported a rare case of Guillain-Barre syndrome after myocardial infarction treated with percutaneous coronary intervention. The patient was a 75-year-old woman from China who was admitted to hospital due to sudden loss of consciousness. Electrocardiography showed acute myocardial infarction in the right ventricle and inferior and posterior walls. The patient underwent emergency percutaneous intervention of the posterior collateral artery of the right coronary artery. Soon after, her condition worsened resulting in limb weakness and numbness. Unfortunately, she continued to develop respiratory failure, and treated with intravenous immunoglobulin and ventilator-assisted breathing. A physical examination showed hypotonia of all four limbs, complete quadriplegia, bulbar palsy, dysarthria, and tendon areflexia. Serum immunoglobulin (Ig) G anti-ganglioside antibody analysis was positive with anti-GT1a antibodies (+ +), anti-GM1 antibodies ( +), anti-GM2 antibodies ( +), and anti-GM4 antibodies ( +), and he was diagnosed with Guillain-Barre syndrome after myocardial infarction. She was discharged due to poor response to treatment. The patient died two days after being discharged.

CONCLUSIONS

Myocardial infarction and/or percutaneous coronary intervention may activate immune-mediated response and cause severe complications. Clinician should be alert to Guillain-Barre syndrome after myocardial infarction and/or percutaneous coronary intervention.

A Rare Case of Guillain-Barré Syndrome Post-gastrojejunostomy and Literature Review

Guillain-Barré syndrome (GBS) is a rare immune-mediated neuropathy causing destruction of the peripheral nervous system, with molecular mimicry playing a major role in its pathophysiology. Despite its rarity, it is considered the most common cause of acute flaccid neuromuscular paralysis in the United States. Although diagnosing GBS depends on the clinical presentation of the patient, cerebrospinal fluid sampling, nerve conduction studies, electromyography, magnetic resonance imaging, and ganglioside antibody screening can be used to confirm the diagnosis and rule out other differentials. Here, we report a rare case of GBS as a postoperative complication after a successful gastrojejunostomy to excise an adenocarcinoma in the second part of the duodenum. Such a complication is rare and not fully understood yet.

Acute Onset of Guillain-Barré Syndrome after Multiple Spine Surgeries: A Rare Case Report

Guillain-Barré syndrome is an autoimmune disorder presented by ascending paralysis and areflexia. The condition has been reported after many infections, but Guillain-Barré syndrome after spine surgery is rare. We, herein, present a case of Guillain-Barré syndrome after multiple spine surgeries for degenerative lumbar scoliosis. A 60-year-old woman with degenerative scoliosis underwent surgery for the third time and developed Guillain-Barré syndrome 3 weeks after the final operation. The patient received intravenous immune globulin therapy and needed mechanical ventilation and intensive care. She was discharged in good condition after 5 weeks.

Sex differences in Guillain Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy and experimental autoimmune neuritis

Guillain Barré syndrome (GBS) and its variants, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP and its variants, are regarded as immune mediated neuropathies. Unlike in many autoimmune disorders, GBS and CIDP are more common in males than females. Sex is not a clear predictor of outcome. Experimental autoimmune neuritis (EAN) is an animal model of these diseases, but there are no studies of the effects of sex in EAN. The pathogenesis of GBS and CIDP involves immune response to non-protein antigens, antigen presentation through non-conventional T cells and, in CIDP with nodopathy, IgG4 antibody responses to antigens. There are some reported sex differences in some of these elements of the immune system and we speculate that these sex differences could contribute to the male predominance of these diseases, and suggest that sex differences in peripheral nerves is a topic worthy of further study.

Guillain-Barre Syndrome following lower segment caesarean section under spinal anesthesia: A case report

Symptoms of Guillain–Barre Syndrome (GBS) may be mistaken for typical puerperal changes, delaying diagnosis. Surgery and anesthesia may be triggers for GBS with an overall increase in pro‐inflammatory cytokines in the postpartum period. We report a unique case of GBS in the postpartum period who made a good recovery with supportive measures.

Guillain–Barre Syndrome (GBS) symptoms may be misinterpreted as usual puerperal changes. Prompt diagnosis and management are crucial to minimize complications. We report a case wherein we managed a post‐surgical GBS with conservative agents resulting full recovery.

Case Report: Delayed Guillain-Barré syndrome following trauma: A case series and manage considerations

Aim

To analyze clinical associations between Guillain-Barré syndrome (GBS) and trauma.

Material and Methods

We retrospectively reviewed the data of eight patients with post-traumatic GBS between July 2011 and December 2018 at the Second Xiangya Hospital, China, and analyzed the triggers, clinical manifestation, examination results, treatment, prognosis, and potential mechanism related to post-traumatic GBS.

Results

The included patients had GBS preceded by no risk factors other than trauma. Their age ranged from 15 to 60 years (the median age was 52 years), and six patients were males. The potential traumatic triggers included spinal surgery (n = 2), high-intensity exercise (n = 2), traumatic brain injury (n = 1), excessive fatigue (n = 1), ischemic stroke (n = 1), and cardiopulmonary resuscitation (n = 1). The major manifestation was symmetrical limb weakness and/or numbness in all patients. The diagnosis of GBS was based on the results of electromyography, albumino-cytological dissociation, or antiganglioside antibody in cerebrospinal fluid, and other diseases were excluded. Immunotherapy improved symptoms, except in one patient who died.

Conclusions

Trauma is a probable risk factor for GBS that is very easily overlooked, thereby leading to misdiagnosis in clinical practice. We emphasize a new concept of post-traumatic GBS to promote doctors' awareness when they meet people with weakness and sensory deficits after trauma, which benefit early diagnosis, timely treatment, and reduced mortality rate of GBS.

Very rare incidence of ascending paralysis in a patient of traumatic spinal cord injury: a case report

INTRODUCTION

After spinal cord injury, further neurological deterioration up to one to two neurological levels is not uncommon. Late neurological deterioration can occur after two months, mainly due to the syrinx formation. In a rare case like in sub-acute post-traumatic ascending myelopathy, the neurological level may ascend more than four levels from the initial level of injury and it usually starts within a few weeks after injury.

CASE PRESENTATION

Our case was diagnosed as a case of traumatic spinal cord injury having a lower thoracic neurological level of injury initially, which rapidly progressed over a few weeks into a higher thoracic neurological level. He was operated with pedicle screw fixation of the spine before admission to rehabilitation unit. He was having progressive ascending neurological deterioration, starting a few days after surgery, which was evident by the progression of neurological level by more than four segments clinically. Cerebrospinal fluid(CSF) study showed no significant abnormality. Magnetic resonance imaging (MRI) study showed involvement of the spinal cord at the upper thoracic region. Patient was monitored to note any further worsening. Rehabilitation and supportive measures were provided according to standard protocol.

DISCUSSION

Very few cases of ascending paralysis of more than four levels have been reported globally. It results in increased morbidity and mortality in spinal cord injury patients. In our case few possible reasons are ruled out but the actual underlying reason was not clear. Various hypotheses have been proposed as the cause in previous published literatures. Management is mostly supportive.

Fatal Autonomic Dysfunction Due to Guillain-Barré Syndrome After Cardiac Surgery

Guillain-Barré syndrome, a rare peripheral neuropathy, appears to occur more often in patients who have recently undergone surgery than in the general population. However, the pathophysiologic relationship between surgery and Guillain-Barré syndrome is elusive. Few cases of Guillain-Barré syndrome after cardiac surgery have been reported. Autonomic dysfunction, a serious complication of Guillain-Barré syndrome, has not been previously reported after cardiac surgery. We describe the case of a 71-year-old woman in whom the acute motor axonal neuropathic subtype of Guillain-Barré syndrome developed after mitral valve replacement. Despite plasmapheresis and intravenous immunoglobulin therapy, she died of complications from severe autonomic dysfunction 25 days postoperatively. Recognizing the potential cardiovascular involvement of Guillain-Barré syndrome is important, because patients who undergo cardiac surgery can be vulnerable to autonomic dysfunction in the early postoperative period.

Association Between Incident Cancer and Guillain-Barré Syndrome Development: A Nationwide Case-Control Study

BACKGROUND AND OBJECTIVES

Cancer may increase the risk of developing Guillain-Barré syndrome (GBS) due to molecular mimicry or immunosuppression, but the exact relationship is unclear. We aimed to determine the association between incident cancer and the following risk of GBS development.

METHODS

We conducted a nationwide population-based case-control study of all patients with first-time hospital-diagnosed GBS in Denmark between 1987 and 2016 and 10 age, sex and index date-matched population controls per case. We identified incident cancer diagnoses between six months prior to and two months after the GBS index date. We used conditional logistic regression to compute ORs as a measure of relative risk and performed stratified analyses to assess the impact of cancer on GBS risk in strata of calendar-periods, sex and age. In sensitivity analyses, to assess any potential risk of survival bias induced by including cancer diagnoses potentially made after GBS diagnosis, we examined incident cancers in both a broader exposure window (one year before to three months after GBS index date) and a narrower window (six months to one month before the GBS index date).

RESULTS

Of the 2,414 patients with GBS and 23,909 controls included, 49 cases (2.0%) and 138 controls (0.6%) had a recent cancer diagnosis, respectively, yielding a matched odds ratio (OR) of 3.6 (95% confidence interval (CI), 2.6- 5.1) for GBS associated with cancer. Stratification by calendar time, gender and age showed robust results for the association between cancer and GBS, with no major variations. Broadening and narrowing the exposure window produced slightly weakened associations of OR, 2.4 (95% CI, 1.8-3.3) and OR, 2.5 (95% CI, 1.5-4.1), respectively. The GBS ORs were highest for cancers of the lymphatic and hematopoietic tissue (OR, 7.2; 95% CI, 2.9-18.0), respiratory tract (OR, 5.6; 95% CI, 2.7-11.9), prostate and other male genital organ (OR, 5.0; 95% CI, 2.1-11.6) and breast cancer (OR, 5.0; 95% CI, 1.7-14.5).

DISCUSSION

In this large nationwide epidemiologic study, incident cancer was associated with a markedly increased risk of subsequent GBS development. The results suggest that yet unidentified factors present in several types of cancer drive this association.

Guillain-Barre syndrome after coronary artery bypass graft surgery: a case report and literature review

Background

Guillain-Barre syndrome (GBS) is an acute polyradiculoneuropathy, often preceded by an infection. Rarely, it is preceded by a surgical procedure. Most of the postsurgical GBS cases are reported with the neurosurgical, gastrointestinal, orthopedic, and cardiac procedures. GBS is rarely reported after a coronary artery bypass grafting (CABG). To date, only 12 cases have been reported in the literature. Our case is 13th in number and the first case from Pakistan.

Case presentation

We report a case of a 54-year-old man presented with acute flaccid quadriparesis and areflexia after a CABG procedure. He was subsequently diagnosed with an acute inflammatory demyelinating polyneuropathy (AIDP) variant of GBS and underwent five sessions of plasmapheresis. His weakness improved and could ambulate unassisted on follow-up visits.

Conclusion

GBS is a potentially treatable condition if timely diagnosed and managed. It should be considered in every patient presenting with an acute-onset weakness after surgery.

Guillain-Barré syndrome after aortic, tricuspid, and mitral valve surgery

Guillain-Barré syndrome incidence within 8 weeks of a surgical procedure appears to be more common than previously thought. GBS following open-heart surgery is exceedingly rare, perhaps underdiagnosed or underreported given surveillance data incidence. Clinicians should be keenly aware of this association and quickly consider a GBS diagnosis.

Intracerebral haemorrhage and Guillain-Barré syndrome: an exploration of potential pathophysiology

Guillain-Barré syndrome (GBS) is an immune-mediated polyneuropathy classically thought to be caused by infections through the process of molecular mimicry. We report a case of GBS caused by intracerebral haemorrhage and postulate potential theories for the development of GBS following intracerebral haemorrhage and other non-infectious aetiologies by association. We highlight that GBS is an important differential diagnosis in patients developing generalised paresis following intracerebral haemorrhage.

Development of Acute Inflammatory Demyelinating Polyneuropathy 11 Days after Spinal Surgery: A Case Report and Literature Review

Guillain–Barré syndrome (GBS) usually has a good prognosis; however, patients may develop sequelae without prompt treatment. We herein describe an 81-year-old woman who developed acute-onset excruciating thigh pain and weakness in her lower extremities after spinal surgery. We diagnosed acute inflammatory demyelinating polyradiculoneuropathy by a nerve conduction study, which showed findings of demyelination without cerebrospinal fluid analysis because of a spinal prosthesis. Although anti-GM1 and anti-GalNAc-GD1a antibodies were positive, the patient was clinically diagnosed with acute inflammatory demyelinating polyradiculoneuropathy (a subtype of GBS), not acute motor axonal neuropathy. She recovered well with immunoglobulin therapy. A literature review of 18 cases revealed that unexplained weakness, areflexia, and numbness of the extremities after spinal surgery, a shorter time from spinal surgery to symptom onset to general GBS, abnormal nerve conduction study results, normal spinal imaging findings, and the development of atypical symptoms such as cranial and autonomic nerve syndrome and respiratory failure are useful for diagnosing GBS when cerebrospinal fluid examination cannot be performed after spinal surgery.

Guillain-Barré syndrome triggered by surgery in a Chinese population: a multicenter retrospective study

Background

Surgery is a potential trigger of Guillain-Barré syndrome (GBS), a disorder which leads to an autoimmune-mediated attack of peripheral nerves. The present study was designed to explore clinical features of post-surgical GBS compared with those of general GBS in order to provide better clinical advice to patients undergoing surgery.

Methods

The medical records of GBS patients who were seen at 31 tertiary hospitals in southern China between January 1, 2013 and September 30, 2016 were retrospectively analyzed. Post-surgical GBS was defined as symptoms of GBS within 6 weeks after surgery. Clinical features of post-surgical GBS are described and are compared with general GBS.

Results

Among the 1001 GBS patient cases examined in this study, 45 (4.5%) patient cases exhibited symptoms of GBS within 6 weeks of undergoing surgery. Within this group, 36 (80.0%) patients developed initial symptoms of limb weakness. The average interval between surgery and symptom onset was 13.31 days. The most common type of surgery which triggered GBS was orthopedic surgery, followed by neurological surgery. Compared to general GBS, post-surgical GBS was characterized by a higher proportion of severe patients (Hughes functional grading scale (HFGS) score ≥ 3) upon admission and at nadir, higher HFGS scores at discharge, and longer hospital stays. Post-surgical GBS patients also had a significantly higher frequency of the acute motor axonal neuropathy subtype (37.9 vs. 14.2, respectively; P = 0.001).

Conclusion

Surgery is probably a potential trigger factor for GBS, especially orthopedic surgery. Infections secondary to surgery may play a role. The possibility of preceding (post-operative) infections was not excluded in this study. Clinical presentation of post-surgical GBS is characterized by a more severe course and poorer prognosis, and should be closely monitored.

Trial registration

chicTR-RRc-17,014,152.

Development of Acquired Factor V Inhibitor After Surgical Procedure Without the Use of Fibrin Tissue Adhesives: A Case Report

Development of acquired factor V (FV) inhibitor is a rare coagulation disorder. Production of heteroantibodies against bovine FV, a contaminant in fibrin tissue adhesives, is a common cause of this condition in the field of surgery. The development of recombinant thrombin eliminated contamination of bovine FV, and infrequent use of bovine thrombin has decreased the risk of FV inhibitor development. Here, we report the case of a 43-year-old man who had marked prolongation of prothrombin time and activated partial thromboplastin time after surgery. Mixing coagulation studies with normal plasma and patient’s plasma suggested the presence of an inhibitor. Clotting factor assays revealed that FV activity decreased to <1% with positive FV inhibitor titer (9.2 Bethesda units). The diagnosis of the FV inhibitor was confirmed. Overt bleeding was not observed during the course of hospitalization. His coagulation abnormalities rapidly normalized without any medical intervention. A careful review of his medical records revealed that no tissue adhesives were used in the patient, and the FV inhibitor would likely be autoantibodies. Antibiotic use during the perioperative period or the surgical procedure itself may trigger the occurrence of FV inhibitors. This case highlights that FV inhibitor may develop after the surgical procedure even without a history of the use of fibrin tissue adhesives. Surgeons and hematologists should be aware that this rare but potentially life-threatening condition may occur after the surgical procedure.

Trauma-Related Guillain-Barré Syndrome: Systematic Review of an Emerging Concept

Guillain-Barré syndrome (GBS) is mainly associated with preceding exposure to an infectious agent, although the precise pathogenic mechanisms and causes remain unknown. Increasing evidence indicates an association between trauma-related factors and GBS. Here, we performed a systematic review, summarized the current scientific literature related to the onset of GBS associated with trauma, and explored the possible pathogenesis. A literature search of various electronic databases was performed up to May 2020 to identify studies reporting diverse trauma-related triggers of GBS. Data were extracted, summarized descriptively, and evaluated with respect to possible mechanisms. In total, 100 publications, including 136 cases and 6 case series involving GBS triggered by injury, surgery, intracranial hemorrhage, and heatstroke, met our eligibility criteria. The median age of the patients was 53 [interquartile range (IQR) 45-63] years, and 72.1% of the patients were male. The median number of days between the trigger to onset of GBS symptoms was 9 (IQR 6.5-13). Overall, 121 patients (89.0%) developed post-injury/surgical GBS, whereas 13 (9.6%) and 2 (1.5%) patients had preexisting spontaneous intracranial hemorrhage and heatstroke, respectively. The main locations of injury or surgeries preceding GBS were the spine and brain. Based on available evidence, we highlight possible mechanisms of GBS induced by these triggers. Moreover, we propose the concept of "trauma-related GBS" as a new research direction, which may help uncover more pathogenic mechanisms than previously considered for typical GBS triggered by infection or vaccination.

[A case of post-surgical inflammatory neuropathy with lower-extremity weakness after surgery for anorectal malignant melanoma that showed the effectiveness of immunotherapy]

A 59-year-old man with past histories of bronchial asthma and chronic sinusitis underwent transanal resection of anorectal malignant melanoma with general anesthesia. On the third day after surgery, he presented with subacute weakness with right dominant hypoesthesia in the bilateral lower limbs. Tendon reflexes were diminished without pathological reflexes. Blood examination showed increased eosinophils (2,058/μl) and elevated serum immunoglobulin E (675.0 IU/ml). Cerebrospinal fluid examination showed elevated protein (200 mg/dl) without pleocytosis (<5/μl). A nerve conduction study suggested multiple mononeuropathy with motor and axonal dominance in the right tibial, peroneal, and sural nerves. Because of eosinophilia and his past medical history (i.e., bronchial asthma and chronic sinusitis), we initially suspected eosinophilic polyangiitis granulomatosis (EGPA) as the cause of postoperative polyneuropathy. However, his neurological symptoms did not improve despite the decreased eosinophil count after tumor resection, which was inconsistent with EGPA. We biopsied the left sural nerve to exclude EGPA and make a diagnosis. Pathological findings revealed no demyelination, axonal degeneration, or eosinophil infiltration with granuloma formation; however, lymphocyte-dominated inflammation was observed around the epineurial small vessels. Thus, the patient was diagnosed with early onset post-surgical inflammatory neuropathy (PIN) based on his clinical course and the pathological findings. On post-surgery day 48, oral administration of prednisolone (40 mg/day) was started. His neurological symptoms improved quickly and remarkably. Our case suggests that, when multiple mononeuropathy develops early after surgery, PIN should be considered as a differential diagnosis to initiate appropriate treatment based on the pathological condition of neuropathy.

Incidence of Guillain-Barré Syndrome is not Associated with Influenza Vaccination in the Elderly

We aimed to analyze the incidence of Guillain-Barré syndrome (GBS) and its association with influenza vaccination (IV) in the elderly population. This study included 2470 patients hospitalized with GBS (G61.0) between 2014 and 2016 based on the Korean National Health Insurance Service (NHIS) claims data. We reviewed every medical claim in the 42 days preceding GBS diagnosis looking for precedent causes of GBS. To assess the relationship between IV and the development of GBS, data from the NHIS and the National Vaccination Registry were combined and analyzed. Using a self-controlled case series (SCCS) approach, we calculated the incidence rate ratio by setting the risk period as 42 days following vaccination. The annual background incidence of GBS was estimated at 4.15 per 100,000 persons. More than half of the patients with newly developed GBS had a previous infection or surgery. The incidence of GBS within 42 days of IV was estimated at 0.32 per 100,000 vaccinated persons. SCCS analysis showed that the risk of GBS was not significantly higher. While GBS can potentially develop from various infections, no association was found between GBS and IV. These results will contribute to developing an evidence-based vaccine policy that includes a clear causality assessment of adverse events.

Guillain-Barre Syndrome After Craniocerebral Gunshot Injury: First Report

BACKGROUND

Guillain-Barre syndrome (GBS) is a rare but serious disorder involving peripheral nerve inflammatory demyelination characterized by acute onset tetraparesis and areflexia. Generally, GBS is preceded by a bacterial or viral infection, and post-traumatic or postsurgical GBS is rarely seen.

CASE DESCRIPTION

A 41-year-old man with severe craniocerebral gunshot injury and open depressed occipital bone fracture was operated urgently. Two weeks postoperatively, he suffered from sudden quadriparesis. He had flaccid paralysis of his bilateral muscle lower extremities (0/5), along with bilateral upper extremity weakness (2/5).

CONCLUSIONS

We report the first case, to our knowledge, with post-traumatic GBS after craniocerebral gunshot injury. We want to indicate the possibility of post-traumatic GBS in cases of unexplained quadriparesis or quadriplegia after trauma or surgery.

Polyneuropathy in Young Siberian Huskies Caused by Degenerative and Inflammatory Diseases

Polyneuropathy is defined as the simultaneous dysfunction of several peripheral nerves. In dogs, a number of breeds are predisposed to a variety of immune-mediated and/or degenerative inherited forms of polyneuropathy, with laryngeal paralysis and/or megaesophagus as important clinical features of many of these conditions. This case series describes degenerative and inflammatory polyneuropathies in 7 young Siberian huskies that were categorized based on clinicopathological characteristics as follows: (1) slowly progressive laryngeal paralysis and megaesophagus caused by primary axonal degeneration with large fiber loss (n = 2); (2) slowly progressive polyneuropathy without megaesophagus or laryngeal paralysis caused by primary axonal degeneration with large fiber loss (n = 2); (3) acute inflammatory demyelinating neuropathy causing sensory, motor and autonomic nerve deficits (n = 2); and (4) ganglioradiculitis (sensory neuronopathy; n = 1). Based on the predominantly young age at onset, slow progression, relatedness of affected dogs, and clinical and pathological similarities with inherited neuropathies reported in other dog breeds, a hereditary basis for the degenerative polyneuropathies in Siberian huskies is suspected. However, 5 different mutations in 3 genes known to cause polyneuropathy in other dog breeds (NDRG1, ARHGEF10, or RAB3GAP1) were not detected in the affected Siberian huskies suggesting that more genetic variants remain to be identified. This study highlights the varied underlying lesions of polyneuropathies in young Siberian huskies.

Guillain-Barré Syndrome After a Gunshot Wound to the Thoracic Spine

BACKGROUND

Guillain-Barré syndrome (GBS) is a rare but well-documented cause of paralysis, often occurring after infection. Few cases have been reported in association with spinal cord injury (SCI), which masks the characteristic ascending paralysis. To our knowledge, this is the first reported case of confirmed GBS during the clinical course of thoracic paraplegia due to a gunshot wound (GSW).

CASE DESCRIPTION

A 23-year-old male presented with a GSW to the right axilla that lodged in the spinal canal at the level of T4, causing right hemothorax and American Spinal Injury Association A paraplegia. He had full strength in bilateral upper extremities until 2 weeks after the injury, at which time he developed progressive weakness in the arms with associated paresthesias and dyspnea. Within 5 days, he was intubated and nearly quadriplegic. Cerebrospinal fluid analysis and electromyography led to a diagnosis of GBS. He was treated with plasmapheresis and experienced rapid and marked recovery in respiratory and upper extremity motor function.

CONCLUSIONS

The differential diagnosis for new-onset weakness in patients with GSW-induced SCI is complicated by the inability to obtain magnetic resonance imaging. This unique case of GBS in a patient with T4 paraplegia highlights the importance of obtaining a thorough history and using diagnostic tools to explore possibilities beyond surgery.

Guillain-Barré and Acute Transverse Myelitis Overlap Syndrome Following Obstetric Surgery

Introduction

There are rare reports of the occurrence of acute transverse myelitis and Guillain–Barré syndrome after various surgical procedures and general/epidural anaesthesia. The concomitant occurrence of these pathologies is very rare and is called Guillain–Barré and acute transverse myelitis overlap syndrome. In this article, we present the case of a second trimester pregnant patient who developed Guillain–Barré and acute transverse myelitis overlap syndrome.

Case presentation

We report the case of a 16-year-old female patient who underwent a therapeutic termination of pregnancy two weeks prior to the onset of the disease with gradual development of a motor deficit with walking and sensitivity disorders, fecal incontinence. The diagnosis was based on clinical exam, electroneurography and spinal magnetic resonance imaging. Endocrinopathies, infectious diseases, autoimmune and inflammatory diseases, neoplastic diseases and vitamin deficiencies were ruled out. Our patient attended five sessions of therapeutic plasma exchange, followed by steroid treatment, intravenous immunoglobulin with minimum recovery of the motor deficit in the upper limbs, but without significant evolution of the motor deficit in the lower limbs. The patient was discharged on maintenance corticotherapy and immunosuppressive treatment with azathioprine.

Conclusions

We report a very rare association between Guillain–Barré syndrome and acute transverse myelitis triggered by a surgical intervention with general anaesthesia. The overlap of Guillain–Barré syndrome and acute transverse myelitis makes the prognosis for recovery worse, and further studies are needed to establish the first-line therapy in these cases.

Surgery and Guillain-Barré Syndrome: A Single-Center Retrospective Study Focused on Clinical and Electrophysiological Subtypes

BACKGROUND

Surgery-related Guillain-Barré syndrome (GBS) is often underestimated and sometimes difficult to diagnose. This study aimed to elucidate the clinical features and electrophysiological subtypes of post-surgical GBS.

METHODS

We retrospectively reviewed 17 patients who developed post-surgical GBS after a recent surgery between 2015 and 2019. Clinical characteristics, electrophysiological examinations, lumbar puncture results and prognosis were assessed. As controls, we selected 66 patients hospitalized with non-surgical GBS.

RESULTS

The median duration from the surgery to the onset of GBS symptoms was 16.0 days. The main types of surgeries preceding GBS were orthopedic, gastrointestinal and neurosurgery. Symmetrical distal limbs weakness was present in all 17 post-surgical GBS patients. The incidence of respiratory failure, autonomic dysfunction and muscle atrophy in post-surgical GBS patients was significantly higher than that in non-surgical GBS patients. Hughes Functional Grading Scale (HFGS) scores were also higher in the post-surgical GBS group both at the time of peak disease and 6 months after discharge. Electrophysiological studies revealed significant motor amplitudes reduction with relative preserved nerve conduction velocities and distal latencies, suggesting axonal subtypes of GBS.

CONCLUSION

GBS should be considered in patients with rapidly progressive muscle weakness after surgery. Such patients often exhibit axonal subtypes of GBS with severe motor dysfunction, high risk of respiratory failure, and poor prognosis.

Guillain-Barré Syndrome and Posterior Reversible Encephalopathy Syndrome following Spinal Surgery

Guillain-Barré syndrome (GBS) typically occurs after gastroenteritis and respiratory tract infection, but surgery has also been considered one of the triggers. Posterior reversible encephalopathy syndrome (PRES) is a rare complication of GBS. A normotensive female in her 70s presented ascending paralysis and frontal-parieto-occipital subcortical lesions with intermittent hypertension after spinal surgery. Nerve conduction studies revealed demyelinating polyneuropathy. The patient's brain lesions disappeared with amelioration of hypertension. She was diagnosed with the demyelinating form of GBS and PRES caused by intermittent hypertension. Intravenous immunoglobulin G (IVIG) improved her symptoms without exacerbation of the PRES. Surgery can be a trigger of GBS, and GBS can cause PRES by hypertension and present as central nervous lesions. It is important to treat hypertension before using IVIG when PRES is suspected as a complication of GBS, since the encephalopathy can be exacerbated by IVIG. There may be more undiagnosed cases of the coexistence of GBS and PRES after surgery because surgery itself can also cause PRES. Proper control of blood pressure and confirmation of negative central nervous lesions are required to treat GBS patients with IVIG safely.

[Guillain-Barre syndrome complicated on post-operation with renal carcinoma and meningioma: a case report]

Guillain-Barre syndrome (GBS) is an autoimmune disease on the injury of peripheral nerve myelin proteins or axon, of which the acute motor axonal neuropathy (AMAN) as a subtype is of infrequence and an extremely low incidence of post-operation. This article originally reported one case from Peking University People's Hospital on successful treatment of severe GBS (AMAN) on post-operation with renal carcinoma and meningioma. The diagnostic criteria of AMAN refer to AIDP, of which the feature of AMAN suggests a pure motor nerve dysfunction and significant damage on motor axon. It is reported that infection and surgery may induce GBS. The positive result of IgM and IgG was considered the application of ganglioside and blood-brain barrier might be damaged after meningioma surgery which eased the drug to enter the cerebrospinal fluid circulation and induced lesions, therefore the etiology on this GBS case was of high confidence of administrating ganglioside drugs. Autonomic nerve dysfunctions, such as blood pressure fluctuations and arrhythmia could be caused in GBS, of which about 3%-10% of GBS patients would die. Early use of gamma globulin or plasma exchange was recommended internationally, but recently some new ideas, to some extent, of significance on GBS treatment emerged. However, there was still no consensus on GBS treatment systematically all over the world. Till now, the general treatment program on GBS may be still gamma globulin or plasma exchange and a curious judgment of prognosis is essential in order to make a reasonable plan. That it was usually of no omen on severe autonomic nerve dysfunction must be successively monitored, the same as the management of the respiratory tract and nutrition support. The key measures taken on lung recruitment was postural drainage on this case with a low cost but a qualified effectiveness. This case report aimed to deepen the understanding of AMAN and acquaint the cutting-edge advances on the treatment of GBS, as well as providing successful treatment experience for the prevention on similar cases.

Guillain-Barré syndrome and influenza vaccines: current evidence

OBJECTIVE

Guillain-Barré Syndrome (GBS) as a consequence of influenza vaccination is a relevant topic, yet to be clarified, which raises concern both amongst health care personnel and the general population. Every study and pharmacovigilance system point to need of further research and the importance of continuous monitoring of safety regarding influenza vaccines. The aim of the present study is to investigate the publication of new data since the realisation of our meta-analysis of GBS and influenza vaccines (published in 2015).

METHODS

A systematic revision of PubMed, Embase, and Web of Knowledge (WOS) databases has been carried out. These report observational studies assessing GBS risk after the administration of influenza vaccines from May 2014 up to July 20th, 2017.

RESULTS

The research yielded 107 articles. Only three studies met established inclusion criteria and referred to an estimation GBS risk after some influenza vaccine. Two studies investigated GBS risk by the pandemic A/H1N1 vaccine, while only one looked into season vaccines.

CONCLUSIONS

The present systematic review, conducted after the publication of our previous meta-analysis, seems to confirm its previous results. Therefore, GBS should be considered an infrequent adverse effect of influenza vaccination, which should not negatively influence its acceptance. Unfortunately, very few of the systematically surveyed studies meeting inclusion criteria. This fact sharply contrasts with the current consensus as to the need of continuously monitoring the safety of influenza vaccines.

Postoperative Guillain-Barré Syndrome, a Neurologic Complication that Must Not Be Overlooked: A Literature Review

BACKGROUND

Guillain-Barré syndrome (GBS) is an uncommon, yet life-threatening postoperative neuropathic complication that is easily neglected, and hence, timely treatment is not provided in the clinics. This review aims to summarize the clinical features of postoperative GBS, and thus, improve the understanding of postoperative GBS.

METHODS

We reviewed the literature on postoperative GBS and assessed the demographic information, clinical manifestation, operation, time of onset of postoperative GBS, and prognosis.

RESULTS

A total of 33 cases of postoperative GBS were included in this study. The average age of patients with postoperative GBS was 46.9 years, and there was a peak in occurrence of GBS between ages 50 and 70 years. Men seemed more likely to have postoperative GBS than did women, with a ratio of 2.67:1. Progressive muscular weakness, present in 31 of the cases, was the most common presentation. Patients with spinal surgery were at further increased risk for GBS, and 84.8% of the patients with GBS had a good prognosis after prompt treatment.

CONCLUSIONS

Surgery is probably a potential risk factor for the occurrence of GBS. Early diagnosis and prompt treatment are imperative to reduce mortality.

Inflammatory demyelinating polyneuropathy after total hip arthroplasty

Inflammatory demyelinating polyneuropathy is a rare but devastating condition. Guillain-Barré syndrome is the most common cause with acute inflammatory demyelinating polyneuropathy being the most common subtype that follows a monophasic course and does not recur. Chronic inflammatory demyelinating polyneuropathy occurs when symptoms persist for greater than 8 weeks. With many proposed etiologies, few reports have described acute inflammatory demyelinating polyneuropathy after total joint arthroplasty. To our knowledge, this is the first case report of chronic inflammatory demyelinating polyneuropathy developing after total hip arthroplasty that was further complicated by dislocation.

Clinical Characteristics of Intravenous Injection of Monosialotetrahexosyl Ganglioside Sodium-Related Guillain-Barre Syndrome

Introduction: Guillain Barre Syndrome (GBS) is an acute inflammatory immune-mediated multiple nerve root neuropathy. GBS primarily damages the spinal nerve root and peripheral nerves, but can also affect the cranial nerves and cause acute demyelination. This study analyzed the clinical features of intravenous injection of monosialotetrahexosyl ganglioside sodium-related Guillain-Barre syndrome (GRD-GBS). Methods: We retrospectively studied 12 patients who developed GRD-GBS after receiving monosialotetrahexosyl ganglioside sodium treatment in association with recent trauma, surgery, acute cerebrovascular disease, or chronic peripheral neuropathy. Clinical characteristics, electrophysiological examinations, serum-specific antibodies, and prognosis were assessed. As controls, we selected 12 patients hospitalized with non-ganglioside-related (NGRD)-GBS. Results: The positive rate of the ganglioside antibody test was significantly higher in the GRD-GBS group (66.67%) than in the NGRD-GBS group (8.33%). CSF protein levels were similar between the groups, but the incidence of blood-nerve-barrier (BNB) disruption was higher in the GRD-GBS group. Patient scores for the Hughes Functional Grading Scale (HFGS), a disability scale, were higher (more severe disability) in the GRD-GBS group than in the NGRD-GBS group. The HFGS scores of the GRD-GBS group did not change between peak onset and 30 days after discharge, but did change significantly by 90 days after discharge, while scores were significantly lower at both 30 and 90 days after discharge in the NGRD-GBS group. Conclusions: GRD-GBS patients showed more severe clinical manifestations, poorer prognosis, and slower recovery than patients with NGRD-GBS. Ganglioside treatment should be used with extreme caution in patients with trauma that damages the BNB.

Incidence and outcome of Guillain-Barré syndrome in Iceland: A population-based study

OBJECTIVE

In this study, we determine the incidence and outcomes of Guillain-Barré syndrome (GBS) in Iceland over a 20-year period.

METHOD

Cases were identified from the records of both referral hospitals in the country. All cases met the Brighton Criteria for GBS. Disability was assessed at diagnosis, peak of symptoms, discharge, and follow-up using the Guillain-Barré Disability Scale.

RESULTS

Sixty-three individuals fulfilled the diagnostic criteria with an average age of onset of 46 years (range 1-89 years) and a male:female ratio of 1. The average annual incidence was 1.1 per 100 000 person-years. Nerve conduction studies were consistent with demyelinating polyneuropathy in 87% of cases, acute motor axonal neuropathy (AMAN) in 4%, and were normal in 9%. Treatment was received by 89% of patients and included IVIG (84%), plasmapheresis (8%), or both treatments (3%). Mechanical ventilation was required by 22% of patients. Long-term follow-up with an average length of 6.5 years was available for 98% of patients, and the average GBS disability score at follow-up was 0.9. Four deaths related to GBS (6%) were observed.

CONCLUSION

We believe we have identified all patients diagnosed with GBS in Iceland during the study period, with an incidence comparable to recent studies from well-defined populations around the world. Our reported mortality is similar to or higher than other population-based studies. At follow-up, 13% of patients still required a walking aid, but most survivors (74%) had minor or no symptoms.

Guillain-Barré syndrome after cardiac surgery: diagnostic dilemma

Guillain-Barré Syndrome after cardiac surgery is very uncommon. Mechanism remains elusive although immunological reaction post surgery has been postulated. This disease can potentially increase the morbidity of the postoperative patients and generally cannot be explained by the cardiac disease or interventions. It is very much essential to diagnose the condition as appropriate management can substantially and profoundly change the course of treatment.

Surgery and risk of Guillain-Barré syndrome: A French nationwide epidemiologic study

OBJECTIVE

To assess the association between Guillain-Barré syndrome (GBS) and recent surgery based on French nationwide data.

METHODS

Data were extracted from the French health administrative databases (SNIIRAM/PMSI). All patients hospitalized for GBS between 2009 and 2014 were identified by ICD-10 code G61.0 as main diagnosis. Patients previously hospitalized for GBS in 2006, 2007, and 2008 were excluded. Surgical procedures were identified from the hospital database. Hospitalizations for surgery with no infection diagnosis code entered during the hospital stay were also identified. The association between GBS and a recent surgical procedure was estimated using a case-crossover design. Case and referent windows were defined as 1-60 days and 366-425 days before GBS hospitalization, respectively. Analyses were adjusted for previous episodes of gastroenteritis and respiratory tract infection, identified by drug dispensing data.

RESULTS

Of the 8,364 GBS cases included, 175 and 257 patients had undergone a surgical procedure in the referent and case windows, respectively (adjusted odds ratio [OR] = 1.53, 95% confidence interval [CI]: 1.25-1.88). A slightly weaker association was observed for surgical procedures with no identified infection during the hospitalization (OR = 1.40, 95% CI: 1.12-1.73). Regarding the type of surgery, only surgical procedures on bones and digestive organs were significantly associated with GBS (OR and 95% CI = 2.78 [1.68-4.60] and 2.36 [1.32-4.21], respectively).

CONCLUSION

In this large nationwide epidemiologic study, GBS was moderately associated with any type of recent surgery and was more strongly associated with bone and digestive organ surgery.

Gullain-Barré syndrome following off-pump coronary artery bypass grafting

We report a case of Gullain-Barré syndrome after off-pump coronary artery bypass grafting surgery in a diabetic male with idiopathic thrombocytopenic purpura who recovered fully after treatment with intravenous immunoglobulin without any residual weakness.

Effector/memory CD8+ T cells synergize with co-stimulation competent macrophages to trigger autoimmune peripheral neuropathy

Autoimmune peripheral neuropathy (APN) such as Guillain Barre Syndrome (GBS) is a debilitating illness and sometimes life threatening. The molecular and cellular mechanisms remain elusive but exposure to environmental factors including viral/bacterial infection and injury is highly associated with disease incidence. We demonstrated previously that both male and female B7.2 (CD86) transgenic L31 and L31/CD4KO mice develop spontaneous APN. Here we further reveal that CD8⁺ T cells in these mice exhibit an effector/memory phenotype, which bears a resemblance to the CD8⁺ T cell response following persistent cytomegalovirus (CMV) infection in humans and mice, whilst CMV has been considered as one of the most relevant pathogens in APN development. These activated, peripheral myelin Ag specific CD8⁺ T cells are required for the disease initiation. While an injury to a peripheral nerve results in Wallerian degeneration in control littermates, the same injury accelerates the development of APN in other non-injured nerves of L31 mice which have a predisposed inflammatory background consisting of effector/memory CD8⁺ T (CD8⁺ T_EM) cells. However, CD8⁺ T_EM cells alone are not sufficient. A certain threshold of B7.2 expression on nerve macrophages is an additional requisite. Our findings reveal that indeed, the synergism between CD8⁺ T_EM cells and co-stimulation competent macrophages is crucial in inducing autoimmune-mediated peripheral neuropathy. The identification of decisive molecular/cellular players connecting environmental triggers and the occurrence of APN provides opportunities to prevent disease onset, reduce relapses and develop new therapeutic strategies.

Clinical factors associated with Guillain-Barré syndrome following surgery

Background

We sought to identify clinical associations and potential triggers of Guillain-Barré syndrome (GBS) within 6 weeks of surgery.

Methods

We retrospectively reviewed consecutive patients diagnosed with GBS within 6 weeks of a surgery between January 1995 and June 2014 at Mayo Clinic. Postsurgical GBS was defined as symptom onset within 6 weeks of surgery. Patients with postsurgical GBS were compared with patients who did not have a surgery prior to GBS onset to determine differences between groups.

Results

A total of 208 patients with GBS, median age 55 years (interquartile range [IQR] 41-68), were included. Nineteen patients (9.1%) developed postsurgical GBS. Median duration from the surgery to onset of first GBS symptom was 15 days (IQR 9-37). The main types of surgeries preceding GBS were gastrointestinal, orthopedic, and cardiac. General anesthesia was used in 18 (95%) and conscious sedation in 1 (5%) patient. Among the 19 patients with postsurgical GBS, 11 (57.9%) had a known diagnosis of malignancy. Autoimmune conditions were present in 5 (26.3%) patients. Postoperative infection was found in 4 (21%) patients. On univariate analysis, the factors that showed an association with postsurgical GBS were age (p = 0.02), malignancy (p ≤ 0.0004), active malignancy (p = 0.03), preexisting autoimmune disorder (p = 0.02), and infection (p = 0.0001). On multivariate analysis, only active malignancy (0.03) remained associated.

Conclusions

Surgery antedated GBS in 9.1% of patients. Postsurgical GBS was more common in patients with an active malignancy. A prospective study is needed to determine whether active malignancy represents an independent risk factor for the development of postsurgical GBS.