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Belgrado E, Del Negro I, Bagatto D, Lorenzut S, Merlino G, Gigli GL, Valente M. Posterior Reversible Encephalopathy Syndrome in Guillain-Barré Syndrome: Just a Problem of Immunoglobulins? Controversy From Two Atypical Case Reports. Front Neurol 2022; 13:817295. [PMID: 35463144 PMCID: PMC9020620 DOI: 10.3389/fneur.2022.817295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS), or the coexistence of these two entities shares similar risk factors and clinical features. For these conditions, a common origin has been supposed. Even if the majority of patients show a favorable course and a good prognosis, a small percentage of cases develop neurological complications. Up to date, only about 30 cases of PRES associated with Guillain-Barré syndrome (GBS) have been reported in the literature. Cases Here, we present two cases of a particularly aggressive PRES/RCVS overlap syndrome, associated with acute motor axonal neuropathy (AMAN) and acute inflammatory demyelinating polyneuropathy (AIDP) variants of GBS, respectively, presenting with similar initial clinical aspects and developing both an atypical and unfavorable outcome. On MRI examination, the first patient showed typical aspects of PRES, while, in the second case, radiological features were atypical and characterized by diffusion restriction on the apparent diffusion coefficient (ADC) map. The first patient demonstrated rapid worsening of clinical conditions until death; the second one manifested and maintained neurological deficits with a permanent disability. Conclusions We suggest that PRES may conceal RCVS aspects, especially in most severe cases or when associated with a dysimmune syndrome in which autoimmune system and endothelial dysfunction probably play a prominent role in the pathogenesis. Although the role of IVIg treatment in the pathogenesis of PRES has been proposed, we suggest that GBS itself should be considered an independent risk factor in developing PRES.
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Affiliation(s)
- Enrico Belgrado
- Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Ilaria Del Negro
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
- *Correspondence: Ilaria Del Negro
| | - Daniele Bagatto
- Neuroradiology Unit, Department of Imaging, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Simone Lorenzut
- Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
| | - Gian L. Gigli
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine University Hospital, Udine, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
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Acute vision loss in Guillain–Barré syndrome: A case series and review of literature. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2022. [DOI: 10.1186/s41983-022-00462-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Bernardes C, Silva C, Santo G, Correia I. Posterior reversible encephalopathy syndrome following Miller-Fisher syndrome. BMJ Case Rep 2021; 14:14/7/e242231. [PMID: 34266817 DOI: 10.1136/bcr-2021-242231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 71-year-old woman presented to the emergency room with dysphonia, diplopia, dysphagia and generalised weakness since that day. Neurological examination revealed eye adduction limitation, ptosis, hypoactive reflexes and gait ataxia. Blood and cerebrospinal fluid analysis and brain CT were normal. Electromyography revealed a sensory axonal polyneuropathy. She was diagnosed with Miller-Fisher syndrome (MFS) and started on intravenous immunoglobulin. Two days after intravenous immunoglobulin treatment was completed, she developed a sustained hypertensive profile and presented a generalised tonic-clonic seizure. Brain MRI was suggestive of posterior reversible encephalopathy syndrome (PRES) and supportive treatment was implemented with progressive improvement. PRES may be a possible complication of MFS not only due to autonomic and inflammatory dysfunctions, but also as a consequence of its treatment. Patients with MFS should be maintained under close surveillance, especially in the first days and preferably in intermediate care units.
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Affiliation(s)
- Catarina Bernardes
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cristiana Silva
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gustavo Santo
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Inês Correia
- Neurology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Garrido D, Martins J, Jordão M, Raimundo P, Jacinto R, Estevens R, Taveira I, Macedo A, Nzwalo H. Triggers of posterior reversible encephalopathy in Guillain-Barre syndrome. Clin Neurol Neurosurg 2020; 198:106250. [DOI: 10.1016/j.clineuro.2020.106250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
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Xiromerisiou G, Kalampokini S, Rikos D, Provatas A, Tsouris Z, Markou K, Ralli S, Dardiotis E. Posterior reversible encephalopathy in a GT1a positive oculopharyngeal variant of Guillain-Barré syndrome: A case-report and review of the literature. Clin Neurol Neurosurg 2020; 196:106037. [DOI: 10.1016/j.clineuro.2020.106037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/18/2020] [Accepted: 06/19/2020] [Indexed: 11/16/2022]
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Hu J, Luo X, Wang Y, Prado E, Fu Q, Shao A. Fulminant Guillain-Barré Syndrome and Spontaneous Intraventricular Hemorrhage: A Case Report and Literature Review. Front Neurosci 2020; 14:633. [PMID: 32714131 PMCID: PMC7340086 DOI: 10.3389/fnins.2020.00633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/22/2020] [Indexed: 11/22/2022] Open
Abstract
Guillain–Barré syndrome (GBS) is an acute, immune-mediated inflammatory peripheral polyneuropathy that is characterized by flaccid paralysis. A few cases have reported that GBS can be caused by head trauma or neurosurgery, but it has never been associated with intraventricular hemorrhage. Here, we report an uncommon case of fulminant GBS that occurred after spontaneous intraventricular hemorrhage. A 73-year-old woman was admitted to the hospital after sudden unconsciousness and vomiting. A head computed tomography (CT) scan following the incident showed a newly developed intraventricular hemorrhage, which led to an immediate ventriculostomy. After 5 days, the endotracheal tube was removed. Two days later, the external ventricular drainage tube was also removed. At this time, the patient was alert and the neurological examination was normal. However, the patient suddenly presented with acute respiratory failure and bilateral limb weakness 3 days later. An analysis of the patient’s cerebrospinal fluid (CSF) revealed that albuminocytologic dissociation was present. The patient was treated with intravenous immunoglobulin (0.4 g/kg/day) for 5 days. Despite timely medical intervention in the hospital, the patient passed away 2 months later. After a cerebral hemorrhagic injury, limb and respiratory muscle weakness can occur on occasion in the ICU. In this context, the potential involvement of GBS should not be ignored. Importantly, the pathogenic mechanism of GBS has been discussed for over a century, and it still remains a mystery. We speculate that the TLR4/NF-κB signaling pathway may be involved in the pathogenesis of GBS following intraventricular hemorrhage. The prognosis of most patients with GBS is usually good, but cerebral hemorrhage and mechanical ventilation may serve as risk factors that exacerbate the condition. This case is reported to remind clinicians to consider the possibility of GBS when patients present limb and respiratory muscle weakness after intraventricular hemorrhage, and to provide a starting point to discuss potential mechanisms of GBS after intraventricular hemorrhage.
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Affiliation(s)
- Jun Hu
- Department of Surgical Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoqian Luo
- Department of Surgical Intensive Care Unit, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yu Wang
- Department of Pediatrics, Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Eric Prado
- Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Qinghui Fu
- Department of Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Anwen Shao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Statin-Associated Necrotizing Autoimmune Myositis Complicated by an Uncommon Adverse Effect to Treatment. Case Rep Med 2019; 2019:4601304. [PMID: 31341481 PMCID: PMC6614968 DOI: 10.1155/2019/4601304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/22/2019] [Accepted: 06/09/2019] [Indexed: 01/03/2023] Open
Abstract
Statin-associated necrotizing autoimmune myositis (NAM) is an autoimmune condition characterized by severe acute-onset proximal muscle weakness, a very high creatinine kinase (CK) level, and prominent myofiber necrosis and minimal lymphocytic infiltration on muscle biopsy. Unlike self-limited statin myopathy, this condition usually requires aggressive immunomodulation therapy to assist recovery and prevent future disability. In this case report, we present a patient who developed progressive muscle weakness after taking atorvastatin for one year. At initial presentation, her CK level was 28,000 U/L. She was diagnosed with statin-associated NAM and started on high-dose intravenous solumedrol, mycophenolate, and intravenous immunoglobulin (IVIG) therapy. However, she subsequently developed acute bilateral vision loss and right side hemineglect; she was diagnosed with posterior reversible encephalopathy syndrome (PRES), thought to be a possible delayed adverse reaction to IVIG. IVIG was discontinued, and the patient was treated with supportive therapy. At six-month follow-up, she had significant improvement in muscle strength and vision.
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Muniz BC, Ribeiro BNDF, Ventura N, Gasparetto EL, Marchiori E. Primary intraosseous meningioma: atypical presentation of a common tumor. Radiol Bras 2018; 51:412-413. [PMID: 30559564 PMCID: PMC6290742 DOI: 10.1590/0100-3984.2017.0106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
| | | | - Nina Ventura
- Instituto Estadual do Cérebro Paulo Niemeyer, Brazil
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Zaeem Z, Siddiqi ZA, Zochodne DW. Autonomic involvement in Guillain-Barré syndrome: an update. Clin Auton Res 2018; 29:289-299. [PMID: 30019292 DOI: 10.1007/s10286-018-0542-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Guillain-Barré syndrome (GBS), an inflammatory, usually demyelinating polyradiculopathy, is characterized by ascending symmetrical limb weakness, sensory disturbances, and absent or reduced deep tendon reflexes. There is extensive literature suggesting that GBS is associated with autonomic dysfunction in up to two-thirds of patients. However, it is interesting that there is still no consensus amongst medical professionals regarding whether GBS patients should be routinely screened for autonomic nervous system (ANS) neuropathy. This is an important issue, as the mortality rate from presumed ANS abnormalities now exceeds that of respiratory failure. Given the long interval since this literature was last comprehensively reviewed, an update on this topic is warranted. METHODS A PubMed search yielded 193 results with the terms "GBS or Guillain-Barré syndrome and autonomic symptoms" and 127 results with the terms "GBS or Guillain-Barré syndrome and dysautonomia." RESULTS This review will summarize the current literature involving GBS and autonomic dysfunction in terms of presentation, management, and a brief discussion of prognosis. We also examine prospective approaches that may be helpful and update a proposed management plan.
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Affiliation(s)
- Zoya Zaeem
- Division of Neurology, University of Alberta, 7-132A Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Zaeem A Siddiqi
- Division of Neurology, University of Alberta, 7-132A Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada
| | - Douglas W Zochodne
- Division of Neurology, University of Alberta, 7-132A Clinical Sciences Building, 11350-83 Ave, Edmonton, AB, T6G 2G3, Canada.
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Guo Y, Tian X, Wang X, Xiao Z. Adverse Effects of Immunoglobulin Therapy. Front Immunol 2018; 9:1299. [PMID: 29951056 PMCID: PMC6008653 DOI: 10.3389/fimmu.2018.01299] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/24/2018] [Indexed: 01/09/2023] Open
Abstract
Immunoglobulin has been widely used in a variety of diseases, including primary and secondary immunodeficiency diseases, neuromuscular diseases, and Kawasaki disease. Although a large number of clinical trials have demonstrated that immunoglobulin is effective and well tolerated, various adverse effects have been reported. The majority of these events, such as flushing, headache, malaise, fever, chills, fatigue and lethargy, are transient and mild. However, some rare side effects, including renal impairment, thrombosis, arrhythmia, aseptic meningitis, hemolytic anemia, and transfusion-related acute lung injury (TRALI), are serious. These adverse effects are associated with specific immunoglobulin preparations and individual differences. Performing an early assessment of risk factors, infusing at a slow rate, premedicating, and switching from intravenous immunoglobulin (IVIG) to subcutaneous immunoglobulin (SCIG) can minimize these adverse effects. Adverse effects are rarely disabling or fatal, treatment mainly involves supportive measures, and the majority of affected patients have a good prognosis.
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Affiliation(s)
- Yi Guo
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xin Tian
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xuefeng Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Zheng Xiao
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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11
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Salata TM, Antunes LDO, Ribeiro BNDF, Borges RS, Corrêa DG. Nonketotic hyperglycemia with involuntary movements. Radiol Bras 2017; 50:338-339. [PMID: 29085169 PMCID: PMC5656076 DOI: 10.1590/0100-3984.2015.0253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Chen PR, Chen SP. Posterior reversible encephalopathy as the first manifestation of Bickerstaff's brainstem encephalitis. BMC Neurol 2016; 16:215. [PMID: 27821089 PMCID: PMC5100286 DOI: 10.1186/s12883-016-0737-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/01/2016] [Indexed: 11/14/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) has been associated with Guillain-Barre syndrome in rare cases. Here we report a patient in whom PRES was the presenting manifestation of Bickerstaff’s brainstem encephalitis. Case presentation A 75-year-old woman presented with acute onset of hypertension, headache, blurred vision, and left eyelid drooping. Magnetic resonance imaging of the brain showed characteristic PRES lesions involving the parietal and occipital lobes bilaterally. On the 6th day after symptom onset, the patient developed complete ptosis and external ophthalmoplegia of both eyes, progressive ataxia, and bilateral lower limb weakness. Cerebrospinal fluid analyses revealed albuminocytological dissociation (protein: 66.6 mg/dL, WBC: 0/μl), and nerve conduction studies showed demyelinating sensorimotor polyneuropathy. The patient developed somnolence and a left extensor plantar response on the 8th day. A diagnosis of Bickerstaff’s brainstem encephalitis was made. Treatment with plasmapheresis led to a rapid improvement of clinical symptoms. To date, only five similar cases have been reported, but this is the only case in which PRES developed prior to treatment. Conclusions PRES can be a comorbid condition with Bickerstaff’s brainstem encephalitis, either preceding or following treatment; caution should be used in patients with either syndrome who exhibit atypical presentations.
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Affiliation(s)
- Pei-Ru Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shih-Pin Chen
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, 112, Taiwan. .,Faculty of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan. .,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
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Liu J, Qin J. [Research advances of posterior reversible encephalopathy syndrome in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:787-91. [PMID: 27530801 PMCID: PMC7399525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/01/2016] [Indexed: 11/12/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity affecting the posterior brain, i.e. occipital and parietal lobes. The syndrome are characterized by headaches, altered mental status, seizures, and visual disturbances. Although the pathogenesis remains unclear, endothelial dysfunction may be a key factor. The basic disease may play a crucial role in the incidence of PRES. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. In severe forms, PRES might cause substantial morbidity with sequel and even mortality, as a result of acute hemorrhage or massive posterior fossa edema causing obstructive hydrocephalus or brainstem compression. Early identification, active and appropriate treatment is very important.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, Peking University People's Hospital, Beijing 100044, China.
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Liu J, Qin J. [Research advances of posterior reversible encephalopathy syndrome in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:787-791. [PMID: 27530801 PMCID: PMC7399525 DOI: 10.7499/j.issn.1008-8830.2016.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/01/2016] [Indexed: 06/06/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity affecting the posterior brain, i.e. occipital and parietal lobes. The syndrome are characterized by headaches, altered mental status, seizures, and visual disturbances. Although the pathogenesis remains unclear, endothelial dysfunction may be a key factor. The basic disease may play a crucial role in the incidence of PRES. In most cases, PRES resolves spontaneously and patients show both clinical and radiological improvements. In severe forms, PRES might cause substantial morbidity with sequel and even mortality, as a result of acute hemorrhage or massive posterior fossa edema causing obstructive hydrocephalus or brainstem compression. Early identification, active and appropriate treatment is very important.
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, Peking University People's Hospital, Beijing 100044, China.
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