Guillain-Barré syndrome and posterior reversible leukoencephalopathy syndrome: a rare association

PRESenting a Challenge: Posterior Reversible Encephalopathy Syndrome in Pediatric Patients With Guillain-Barré Syndrome: A Case Series and Review of Literature

BACKGROUND

Guillain-Barré syndrome (GBS) is an autoimmune disorder characterized by demyelination of peripheral nerves. GBS-associated posterior reversible encephalopathy syndrome (PRES) is a rare and potentially life-threatening complication in the pediatric population. We aimed to report and analyze the clinical features, management, and outcomes of three cases of GBS-associated PRES in our setting in the light of the existing literature.

METHODS

Medical records of 75 pediatric patients with GBS were reviewed for autonomic changes and GBS-associated PRES. Thirty-one developed dysautonomia while three were identified to have PRES. Clinical, radiological, laboratory, and treatment data were collected and analyzed.

RESULTS

All three patients were male and presented with symptoms of acute flaccid paralysis and respiratory distress requiring mechanical ventilation. All three patients experienced various complications, including hypertension, seizures, and hyponatremia, and were subsequently diagnosed with PRES. Multimodal intensive care resulted in patient improvement and discharge in an ambulatory state after an average of 104 days of care.

CONCLUSIONS

GBS-associated PRES is a rare and potentially life-threatening complication that can occur in pediatric patients with GBS. Our findings suggest that early recognition, prompt intervention, and multimodal intensive care can improve patient outcomes. Further studies are needed to determine optimal treatment strategies for GBS-associated PRES.

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.

Acute vision loss in Guillain–Barré syndrome: A case series and review of literature

Background

Acute vision loss in Guillain–Barré syndrome  is rarely reported in literature. No case of vision loss in Guillain–Barré syndrome due to Angle closure glaucoma  has been reported in AIDP variant GBS.

Case presentation

We report three patients with an acute inflammatory demyelinating polyradiculoneuropathy subtype of GBS who developed acute vision loss during the course of disease. Two patients had autonomic dysfunction with hypertension, in which  one patient presented with painful acute vision loss and was diagnosed with Angle closure glaucoma and another patient had painless vision loss which was due to posterior reversible encephalopathy syndrome. Third patient presented with bilateral papilledema with raised cerebrospinal fluid protein and intracranial pressure. Vision in all the three patients improved after treatment.

Conclusion

Patient with GBS, with autonomic dysfunction and hypertension or elevated cerebrospinal fluid protein may present with acute vision loss during the course of the disease. Early diagnosis and management  help to improve vision and prevent permanent vision loss in these patients.

Co-occurrence of chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids and posterior reversible encephalopathy syndrome: a case report

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is a rare inflammatory disorder, mainly involving the brainstem. Posterior reversible encephalopathy syndrome (PRES) is a syndrome that affects the bilateral parietal-occipital region. Here, we describe a rare case of CLIPPERS with PRES. A 47-year-old woman presented with subacute, progressive ataxia symptoms, and radiological and pathological findings were consistent with CLIPPERS. In addition, she had acute convulsions and was unconscious, and brain magnetic resonance imaging fluid-attenuated inversion recovery showed patchy high-intensity posterior cerebral white matter signals, with imaging lesions showing vasogenic oedema, a typical manifestation of PRES. The imaging lesions showed vasogenic oedema in bilateral parietal and occipital lobes and typical 'pepper-like' punctate gadolinium enhancement in pons and bilateral cerebellar hemispheres, which were considered to be caused by merger of CLIPPERS and PRES. Clinical manifestations and imaging lesions disappeared after two months of steroids and symptomatic treatment, supporting the diagnosis of CLIPPERS with PRES. When patients with CLIPPERS show unusual symptoms or atypical vasogenic oedema lesions in the posterior cerebral white matter, the coexistence of PRES should be considered.

Posterior reversible encephalopathy syndrome in a patient with serotonin syndrome

Serotonin syndrome (SS) is a drug-induced clinical syndrome, characterised by a triad of cognitive impairment, autonomic hyperactivity and neuromuscular abnormalities. Hypertension, one of the common autonomic manifestations in SS, may lead to lead to several life-threatening conditions. Herein, we report a case of SS who had posterior reversible encephalopathy syndrome (PRES) because of high blood pressure.A young male with a 5-month history of chronic tension-type headache and depression had been receiving amitriptyline and paroxetine. Increment of paroxetine led to the development of various new clinical features, fulfilling the Hunter criteria of SS. MRI brain revealed high-signal intensity lesions on T2 fluid-attenuated inversion recovery, and T2-weighted imaging in the posterior regions of the occipital, parietal, temporal and cerebellum lobes, suggestive of PRES. The patient responded to cyproheptadine. Autonomic hyperactivity, due to SS, is the most likely explanation of this association.