Concurrency of Guillain-Barre syndrome and acute transverse myelitis: a case report and review of literature

Concurrent transverse myelitis and acute inflammatory demyelinating polyneuropathy

A woman in her 40s presented with thoracic banding dysaesthesia and lower motor neuron weakness. Spinal imaging revealed a short segment of transverse myelitis and neurophysiology was suggestive of concurrent acute inflammatory demyelinating polyneuropathy. The patient improved with consecutive intravenous immunoglobulin and methylprednisolone treatment. Acute inflammatory demyelinating polyneuropathy is a progressive immune-mediated peripheral neuropathy which responds to intravenous immunoglobulin or plasmapheresis, whereas transverse myelitis is a central inflammatory syndrome usually treated with corticosteroid. We highlight differentiating features of the clinical presentation and the utility of investigations such as neurophysiology and MRI along with a review of treatment and the role for corticosteroid therapy.

A possible Guillain-Barré syndrome/transverse myelitis overlap syndrome after recent COVID-19

Neurological manifestations are common in SARS-CoV-2 infection, including life-threatening acute muscle weakness, due to neuromuscular disorders such as acute transverse myelitis (TM) and Guillain-Barré syndrome (GBS). These syndromes can rarely coexist and present as an overlap syndrome. Here, we report a patient who developed acute symmetrical proximal lower limb weakness 5 days after diagnosis of COVID-19. GBS was diagnosed due to the presence of motor signs, albumin-cytological dissociation in cerebrospinal fluid examination and axonal damage according to nerve condition tests. However, abnormal areas on MRI of the thoracic spine and lack of improvement with intravenous immunoglobulin supported a diagnosis of TM. Therefore, a possible overlap between GBS and TM was established. To our knowledge, this is the third case report of GBS/TM overlap syndrome after COVID-19. The patient’s full and rapid recovery with intravenous corticosteroids and plasmapheresis supports our diagnosis.

Acute Polyradiculomyelitis With Spinal Cord Gray Matter Lesions: A Report of Two Cases

Objective: Inflammatory polyradiculomyelitis belongs to a rare group of immune-mediated diseases affecting both the central and peripheral nervous system. We aimed to describe an unusual presentation of acute polyradiculomyelitis with marked spinal cord lesions restricted to the gray matter.

Methods: Thorough examination of two case reports including clinical, MRI, serologic, electrophysiologic and CSF examinations as well as short-term follow-up.

Results: We present two adult patients with acute polyradiculomyelitis and unusual spinal cord lesions restricted to the gray matter on MRI. The clinical presentation, serologic, electrophysiologic and CSF features of the two patients varied, whereas both patients demonstrated severe, asymmetrical, predominantly distal, motor deficits of the lower extremities as well as bladder and bowel dysfunction. Both patients only partially responded to anti-inflammatory treatment. Severe motor impairment and bladder dysfunction persisted even months after symptom onset.

Conclusions: To our best of knowledge, these are the first reports of acute polyradiculomyelitis with distinct involvement of the lower thoracic spinal cord gray matter. Currently, it remains unclear whether gray matter lesions reflect a separate pathophysiologic mechanism or an exceedingly rare presentation of spinal cord involvement in acute polyradiculomyelitis.

Young woman with Guillain-Barré syndrome and cervical transverse myelitis-A new GBS variant, not coincidence

A case of antibody proven Guillain Barré Syndrome in a previously healthy young female with extra clinical features, scans, and physical exam findings consistent with cervical spine and cervical medullary junction myelitis, together a new variant to consider.

Association between Helicobacter pylori infection and Guillain-Barré Syndrome: A meta-analysis

BACKGROUND

Helicobacter pylori (H pylori) is a Gram-negative bacterium, considered to trigger autoimmune gastrointestinal disorders. This pathogen has also been linked to the autoimmune sequelae in extra-gastrointestinal diseases and peripheral neuropathies. Guillain-Barré syndrome (GBS) is a serious autoimmune demyelinating disorder of peripheral nerves, usually with a post-infectious onset. About 30% of cases of GBS attributed to by Campylobacter jejuni, so, H pylori, could be also involved. Growing evidence suggests the likely involvement of H pylori infection in the development of GBS. The aim of the current study was to therefore estimate the prevalence of H pylori antibodies in GBS.

METHODS

A search of the literature was performed, using the PUBMED database, until December 2018. Data were extracted from six case-control studies, and a stratification analysis was conducted according to cerebrospinal fluid (CSF) or serum detection material.

RESULTS

Among 29 records found, 6 studies met in the inclusion criteria for the meta-analysis. In the CSF subgroup, 105 participants were involved (40 GBS patients and 65 controls), while the serum subgroup included 325 participants (152 GBS and 173 controls). Data were combined using a fixed-effects model. Anti-H pylori IgG were significantly more prevalent in GBS patients compared to controls, in both CSF (95% CI: 9.66-186.56, OR: 42.45, Pz < .00001) and serum (95% CI: 1.30-4.11, OR: 2.31, Pz: .004) subgroups.

CONCLUSION

The present meta-analysis showed a strong association between GBS and the presence of H pylori antibodies, especially in CSF, thereby suggesting a role of H pylori infection in the pathophysiology of GBS.

A Rare Case of Acute Transverse Myelitis (ATM) and Acute Motor and Sensory Axonal Neuropathy (AMSAN) Overlap

Concomitant acute transverse myelitis (ATM) and Guillain-Barre syndrome (GBS) is described as GBS and ATM overlap. Its presentation varies greatly, thus making the diagnosis difficult. Overlap syndrome is more commonly associated with acute motor axonal neuropathy (AMAN) subtype of GBS. However, we present a case of a middle-aged gentleman with combined ATM and acute motor and sensory axonal neuropathy (AMSAN) subtype of GBS. This combination is quite rare, and only a few cases have been reported so far.

Clinical features and prognosis of patients with Guillain-Barré and acute transverse myelitis overlap syndrome

OBJECTIVES

Patients who present with Guillain-Barré syndrome (GBS) and acute transverse myelitis (ATM), either simultaneously or consecutively, are defined as having GBS/ATM overlap syndrome. As this syndrome has been underinvestigated, we performed a literature review to evaluate case reports of GBS/ATM overlap syndrome to facilitate its early diagnosis.

PATIENTS AND METHODS

We searched four scientific literature databases (PUBMED, EMBASE, ELSEVIER and WEB OF SCIENCE) for cases that presented as GBS/ATM overlap syndrome. Eighteen articles that described 23 cases were included, and the clinical and prognostic data were analyzed.

RESULTS

Initially, only five (29.4%) patients were diagnosed with GBS/ATM overlap syndrome. Patients with GBS/ATM overlap syndrome presented as four clinical features. First, some of the patients displayed abnormal pyramidal signs, including 29.4% of patients who had positive pyramidal signs or a negative plantar reflex and 17.6% of patients who had signs of areflexia or hyporeflexia combined with positive pyramidal signs. Second, patients suffered pain and respiratory failure at a high rate (43.5% with pain at the onset of the disease, 43.5% with ventilator support, and 47.8% shown with respiratory failure). Third, patients had a partial clinical recovery of immunomodulators, 56.5% of patients had a favorable outcome, 46.2% of patients who received intravenous immunoglobulin (IVIG) combined steroids responded well to the treatment. Four, acute axonal polyneuropathy seemed to be associated with poor outcomes (odds ratio = 3.00, 95% CI = 1.35-6.68, P = 0.01). Abnormalities in spinal cord magnetic resonance imaging (MRI) were detected in all patients, and the most frequently involved segments were the cervical cord (69.6%) and the thoracic cord (69.6%). In addition to spinal cord lesions, in three patients lesions in the medulla and cerebral hemisphere were also observed. The most common prescriptions included a high dose of methylprednisolone at 1 g/day for 3-5 days that was followed by a 6-week course of oral prednisone and IVIG at 0.4 g/kg/day for 5 days.

CONCLUSION

While it is difficult to make an early diagnosis of GBS/ATM overlap syndrome, electrophysiology is helpful in the diagnosis of GBS and spinal cord MRIs are key to identifying ATM. Brain MRIs are also recommended to detect subclinical lesions. The combined use of IVIG and steroids was the most frequent treatment. However, less than half of the patients responded positively to treatment. Acute axonal neuropathy may be a risk factor for a poor prognosis.

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.

Late Controlled Type 2 Diabetes Mellitus with Severe Acute Systemic Infection

Background: The last International Diabetes Federation statement showed that in 2015, there were 415 million people diagnosed with diabetes and the expectation for 2040 is around 642 million people all over the world. Diabetes Mellitus is a disease associated with major negative consequences due to its acute and chronic complications with chronic hyperglycemia playing a major role.

Method: We are presenting a case of 52 year old male patient, known with Type 2 Diabetes Mellitus for 10 years without treatment due to personal decision, who was admitted through the Emergency Unit in Neurology Department for bilateral myalgia of hips and arms, proximal force deficiency of bilateral lower limbs, acute retention of urine, fever, simptomatology which started about 48 before admission. The suspected diagnosis was acute polyradiculoneuritis but the paraclinical investigations performed on Neurology Unit excluded it and evaluated the present disease as Acute Diabetic Neuropathy. Through the passing days, the patient developed paraplegia and major unbalanced glycemic control (although he received multiple rapid human subcutaneous insulin injection) so they’ve decided to transfer him into Diabetology Department. At the moment of admission into Diabetology Unit, the patient had high fever, superficial and deep sensitivity disorders, urethral catheter and no faeces for 7 days. We’ve continued our investigations and came with a positive diagnosis of Unballanced and Complicated Type 2 Diabetes Mellitus with insulin therapy, Parainfectious Acute Transverse Myelitis, Prostatic and Seminal Vesicles Abces with rectal fistula, Sepsis, Acute Retention of Urine, Urina Infection with Pseudomonas Aeruginosa.

Conclusion: The diagnosis of Unballanced Diabetes Mellitus involves differential diagnosis due to lack of specific simptomatology in Diabetic Neuropathy and associated immune deficiency.