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Idogun PO, Hafez-Khayyata S, Ezekwudo D. Immune Checkpoint Inhibitor-Induced Guillain Barre Syndrome: A Single-Institution Case Report and Narrative Review. Cureus 2024; 16:e61489. [PMID: 38952584 PMCID: PMC11216129 DOI: 10.7759/cureus.61489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2024] [Indexed: 07/03/2024] Open
Abstract
Guillain-Barré syndrome (GBS) resulting from the use of immune checkpoint inhibitors (ICIs) is relatively uncommon but has been reported. Herein, we discuss a case of a 67-year-old patient who received neoadjuvant ICI for treatment of non-small cell lung cancer and then presented with lower extremity weakness and areflexia, progressing to respiratory muscle and upper extremity weakness. Given the increasing use of ICI in cancer management, awareness of neurological autoimmune side effects is essential. ICI-mediated GBS can be severe and fatal if not diagnosed promptly. We discuss a case of ICI-induced GBS and review literature on current management approaches.
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Affiliation(s)
- Precious O Idogun
- Hematology and Medical Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Said Hafez-Khayyata
- Pathology, Corewell Health William Beaumont University Hospital, Royal Oak, USA
| | - Daniel Ezekwudo
- Hematology and Oncology, Corewell Health William Beaumont University Hospital, Royal Oak, USA
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Shrestha GS, Nepal G, Prust ML. Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings. Semin Neurol 2024; 44:105-118. [PMID: 38485125 DOI: 10.1055/s-0043-1778638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Rani, Biratnagar, Nepal
| | - Morgan Lippitt Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Rajurkar R, Chavan N, Deodhe N, Baheti NC. Enhancing Tone and Strength in a Patient With Autoimmune Encephalitis and Guillain-Barré Syndrome Using Rood's Facilitatory Techniques and Neuromuscular Electrical Stimulation: A Case Report. Cureus 2024; 16:e56054. [PMID: 38618408 PMCID: PMC11009831 DOI: 10.7759/cureus.56054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/12/2024] [Indexed: 04/16/2024] Open
Abstract
This case report documents the comprehensive management of a 21-year-old female resident of Gadchiroli presenting with a 10-day history of fever, altered consciousness, and neurological sequelae following a traumatic incident. The patient exhibited a Glasgow Coma Scale score of 6/15, hypotonia in both upper and lower limbs, diminished deep tendon reflexes, and respiratory complications. This case study describes a thorough physiotherapeutic strategy that focuses on tone facilitation and muscle weakness improvement. The intervention used Rood's facilitative approaches as well as neuromuscular electrical stimulation (NMES). Rood's treatments, which emphasized mobilizing touch and tactile stimulation, brushing, quick icing, quick stretching, tapping, massaging the skin, heavy joint compression, and rolling, were used deliberately to move the patient from flaccidity to better muscle tone. These techniques' repetitive and task-specific nature coincided with motor learning principles, enabling adaptive modifications in brain networks. Concurrently, NMES was used to improve muscle activation, create a controlled environment for neurorehabilitation, and promote strength increases. The successful integration of various modalities highlights the possibility of favorable neuronal adaptations and functional improvements in individuals suffering from complicated neuromuscular disorders. This case demonstrates the need for individualized and diversified physiotherapeutic techniques in improving rehabilitation outcomes.
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Affiliation(s)
- Reva Rajurkar
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nitika Chavan
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nishigandha Deodhe
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nandini C Baheti
- Neurophysiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Liu S, Zhang WW, Jia L, Zhang HL. Guillain-Barré syndrome: immunopathogenesis and therapeutic targets. Expert Opin Ther Targets 2024; 28:131-143. [PMID: 38470316 DOI: 10.1080/14728222.2024.2330435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 03/10/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Guillain-Barré syndrome (GBS) is a group of acute immune-mediated disorders in the peripheral nervous system. Both infectious and noninfectious factors are associated with GBS, which may act as triggers of autoimmune responses leading to neural damage and dysfunction. AREAS COVERED Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its vaccines as well as flaviviruses have been associated with GBS, although a robust conclusion has yet to be reached. Immunomodulatory treatments, including intravenous immunoglobulins (IVIg) and plasma exchange (PE), have long been the first-line therapies for GBS. Depending on GBS subtype and severity at initial presentation, the efficacy of IVIg and PE can be variable. Several new therapies showing benefits to experimental animals merit further investigation before translation into clinical practice. We review the state-of-the-art knowledge on the immunopathogenesis of GBS in the context of coronavirus disease 2019 (COVID-19). Immunomodulatory therapies in GBS, including IVIg, PE, corticosteroids, and potential therapies, are summarized. EXPERT OPINION The association with SARS-CoV-2 remains uncertain, with geographical differences that are difficult to explain. Evidence and guidelines are lacking for the decision-making of initiating immunomodulatory therapies in mildly affected patients or patients with regional subtypes of GBS.
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Affiliation(s)
- Shan Liu
- Department of Nuclear Medicine, Second Hospital of Jilin University, Changchun, China
| | - Wei Wei Zhang
- Department of Neurology, First Hospital of Jilin University, Jilin University, Changchun, China
| | - Linpei Jia
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hong-Liang Zhang
- Department of Life Sciences, National Natural Science Foundation of China, Beijing, China
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Olbert E, Alhani N, Struhal W. Retrospective analysis of COVID-19 patients with Guillain-Barre, Miller-Fisher, and opsoclonus-myoclonus-ataxia syndromes-a case series. Wien Med Wochenschr 2024; 174:30-34. [PMID: 37523107 PMCID: PMC10810910 DOI: 10.1007/s10354-023-01018-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/23/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND In accordance with the rising number of SARS-CoV‑2 infections, reports of neurological complications have also increased. They include cerebrovascular diseases but also immunological diseases such as Guillain-Barre syndrome (GBS), Miller-Fisher syndrome (MFS), and opsoclonus-myoclonus-ataxia syndrome (OMAS). While GBS and MFS are typical postinfectious complications, OMAS has only recently been described in the context of COVID-19. GBS, MFS, and OMAS can occur as para- and postinfectious, with different underlying pathomechanisms depending on the time of neurological symptom onset. The study aimed to describe clinical features, time between infection and onset of neurological symptoms, and outcome for these diseases. METHODS All COVID-19 patients treated in the neurological ward between January 2020 and December 2022 were screened for GBS, MFS, and OMAS. The clinical features of all patients, with a particular focus on the time of onset of neurological symptoms, were analyzed. RESULTS This case series included 12 patients (7 GBS, 2 MFS, 3 OMAS). All GBS and one MFS patient received immunomodulatory treatment. Three patients (2 GBS, 1 OMAS) had a severe COVID-19 infection and received mechanical ventilation. In patients with OMAS, only one patient received treatment with intravenous immunoglobulin and cortisone. The remaining two patients, both with disease onset concurrent with SARS-COV‑2 infection, recovered swiftly without treatment. In all subgroups, patients with concurrent onset of neurological symptoms and COVID-19 infection showed a trend toward shorter disease duration. CONCLUSION All patient groups displayed a shorter disease duration if the onset of neurological symptoms occurred shortly after the COVID-19 diagnosis. In particular, both the OMAS patients with symptom onset concurrent with COVID-19 showed only abortive symptoms followed by a swift recovery. This observation would suggest different pathomechanisms for immune-mediated diseases depending on the time of onset after an infection.
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Affiliation(s)
- Elisabeth Olbert
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria.
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430, Tulln an der Donau, Austria.
| | - Naela Alhani
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430, Tulln an der Donau, Austria
| | - Walter Struhal
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500, Krems, Austria
- Department of Neurology, University Hospital Tulln, Alter Ziegelweg 10, 3430, Tulln an der Donau, Austria
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James N, Reddy S, Maheshwari U, Elamurugan N, Kumar N, Kumar AN, Tejaswini SD, Ranganathan LN, S B. Incidence of Cardiovascular Instability in Patients With Guillain-Barré Syndrome: A Retrospective Study. Cureus 2024; 16:e52778. [PMID: 38389637 PMCID: PMC10882565 DOI: 10.7759/cureus.52778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Introduction Guillain-Barré syndrome (GBS) is an autoimmune disease affecting radicles and peripheral nerves resulting in acute flaccid paralysis. Respiratory failure, autonomic dysfunction, and secondary complications such as pneumonia, and venous thromboembolism are the major causes of death and disability in GBS. Cardiovascular complications play a major role in the prognosis of GBS patients. The aim is to determine the incidence of cardiovascular instability in GBS patients and to see if there are any specific risk groups associated with the development of cardiovascular instability. Methodology This is a retrospective descriptive study conducted in a tertiary care center in South India. Data on 50 consecutive GBS patients were collected from hospital records including case sheets, death summaries, and discharge summaries. Patients with evidence of sepsis, blood loss, heavy alcohol consumption, and chronic liver disease were excluded from the study. Baseline demographic data, symptom onset to admission time, baseline Erasmus Guillain-Barré Syndrome Respiratory Insufficiency Score (EGRIS), and baseline liver function tests were documented. The presence of heart rate and blood pressure fluctuations was noted from the records. Frequency data were calculated from the categorical variables. Analysis of non-parametric variables by chi-square test was done using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, New York, United States). Results Cardiovascular instability was present in 15 (30%) patients in the study population. It was present in all patients (100%) who require mechanical ventilation. The incidence of cardiovascular instability was higher in patients who had lesser onset to admission times (41.9% vs 10.5%; p=0.019), EGRIS≥4 (40.6% vs 11.1%; p=0.029), and lower cranial nerve involvement (40% vs 6.7%; p=0.018). Conclusion Of patients with GBS, 30% developed cardiovascular instability during their disease course. Patients with lesser onset to admission times, EGRIS ≥4, and those with lower cranial nerve involvement had a greater incidence of cardiovascular instability.
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Affiliation(s)
- Noel James
- Institute of Neurology, Madras Medical College, Chennai, IND
| | - Sanjeeva Reddy
- Institute of Neurology, Madras Medical College, Chennai, IND
| | - Uma Maheshwari
- Institute of Neurology, Madras Medical College, Chennai, IND
| | | | - Nirumal Kumar
- Institute of Neurology, Madras Medical College, Chennai, IND
| | - Arun N Kumar
- Institute of Neurology, Madras Medical College, Chennai, IND
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Galassi G, Mazzoli M, Ariatti A, Bedin R, Marzullo D, Bastia E, Agnoletto V, Gozzi M, Valzania F, Meletti S, Marchioni A. Predictors of respiratory failure in Guillain-Barré syndrome: a 22 year cohort study from a single Italian centre. Eur J Neurol 2024; 31:e16090. [PMID: 37823704 PMCID: PMC11235807 DOI: 10.1111/ene.16090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/23/2023] [Accepted: 09/21/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND AND PURPOSE The study aimed to identify predictors of respiratory failure leading to mechanical ventilation (MV) and tracheostomy in Guillain-Barré syndrome (GBS). METHODS Two hundred and thirty adult cases admitted to the Neurology Unit of Modena, Italy, between January 2000 and December 2021 were studied. A cut-off of MV starting within 8 weeks from onset of weakness was used. Univariable, multivariable logistic and Cox regression analyses were used to determine which pre-specified clinical and diagnostic characteristics were capable of predicting MV and tracheostomy, due to weaning failure. The model was internally validated within the full cohort. The Erasmus GBS Respiratory Insufficiency Score was retrospectively applied. RESULTS One hundred and seventy-six cases (76.5%) were classified as classical sensorimotor GBS and 54 (23.4%) as variants. Thirty-two patients (13.9%) needed MV: 84.3% required respiratory support within 7 days. Independent predictors of respiratory failure and MV were older age, facial, bulbar, neck flexor weakness, dysautonomia, axonal electrophysiological subtype, cardiovascular comorbidities and higher disability score at entry. There was no association with abnormal spinal fluid parameters nor with positive serology for recent infections. Twenty-two patients (68.7%) were ventilated for more than 7 days; 4.7% died within 8 weeks. The patients who required MV were treated more often with plasma exchange. Independent predictors of tracheostomy due to weaning trial failure were facial, bulbar, neck flexor weakness, autonomic dysfunction, associated cardiovascular morbidities and axonal electrophysiological subtype on nerve conduction study. CONCLUSIONS Our study indicates distinct predictors of MV and tracheostomy in GBS patients.
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Affiliation(s)
- Giuliana Galassi
- Department of Biomedical, Metabolic and Neural SciencesUniversity HospitalsModenaItaly
| | - Marco Mazzoli
- Department of Biomedical, Metabolic and Neural SciencesUniversity HospitalsModenaItaly
| | - Alessandra Ariatti
- Department of Biomedical, Metabolic and Neural SciencesUniversity HospitalsModenaItaly
| | - Roberta Bedin
- Department of Biomedical, Metabolic and Neural SciencesUniversity HospitalsModenaItaly
| | - Donato Marzullo
- Department of Biomedical, Metabolic and Neural SciencesUniversity HospitalsModenaItaly
| | | | | | - Manuela Gozzi
- Department of ImagingUniversity Hospitals of ModenaModenaItaly
| | - Franco Valzania
- Neurology Unit, Neuromotor and Rehabilitation DepartmentAzienda USL‐IRCCS di Reggio EmiliaReggio EmiliaItaly
| | - Stefano Meletti
- Department of Biomedical, Metabolic and Neural SciencesUniversity HospitalsModenaItaly
| | - Alessandro Marchioni
- Respiratory Disease Unit, Department of Medical and Surgical SciencesUniversity Hospitals of ModenaModenaItaly
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Gomez F, Mehra A, Ensrud E, Diedrich D, Laudanski K. COVID-19: a modern trigger for Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. Front Neurosci 2023; 17:1198327. [PMID: 37712090 PMCID: PMC10498773 DOI: 10.3389/fnins.2023.1198327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/31/2023] [Indexed: 09/16/2023] Open
Abstract
COVID-19 infection has had a profound impact on society. During the initial phase of the pandemic, there were several suggestions that COVID-19 may lead to acute and protracted neurologic sequelae. For example, peripheral neuropathies exhibited distinctive features as compared to those observed in critical care illness. The peripheral nervous system, lacking the protection afforded by the blood-brain barrier, has been a particular site of sequelae and complications subsequent to COVID-19 infection, including Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. We will discuss these disorders in terms of their clinical manifestations, diagnosis, and treatment as well as the pathophysiology in relation to COVID-19.
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Affiliation(s)
- Francisco Gomez
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Ashir Mehra
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Erik Ensrud
- Department of Neurology, University of Missouri, Columbia, MO, United States
| | - Daniel Diedrich
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, United States
| | - Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN, United States
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Moore O, McLaren S, Newton F. Locked-In Presentation of Guillain-Barre Syndrome Following SARS-COVID-19 Infection. Kans J Med 2023; 16:151-152. [PMID: 37377622 PMCID: PMC10291979 DOI: 10.17161/kjm.vol16.18922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 05/15/2023] [Indexed: 06/29/2023] Open
Affiliation(s)
- Olivia Moore
- Department of Anesthesiology, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Scott McLaren
- Department of Anesthesiology, University of Kansas School of Medicine-Wichita, Wichita, KS
| | - Felecia Newton
- Department of Anesthesiology, University of Kansas School of Medicine-Wichita, Wichita, KS
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AlKahtani NA, Alkhudair JA, Bensaeed NZ, Alshammari YS, Alanazi RF, Khatri IA, Masud N. Guillain-Barré Syndrome in Adults in a Decade: The Largest, Single-Center, Cross-Sectional Study From the Kingdom of Saudi Arabia. Cureus 2023; 15:e40995. [PMID: 37503490 PMCID: PMC10371290 DOI: 10.7759/cureus.40995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Guillain-Barré Syndrome (GBS) is the most common cause of acute, usually post-infectious, peripheral neuropathy resulting in a symmetrical, ascending paralysis. We evaluated the clinical and neurophysiological features, treatment, and outcomes of patients with GBS in our center. METHODS A retrospective chart review on patients with GBS admitted to King Abdulaziz Medical City, Riyadh, Saudi Arabia, from January 2011 to December 2020. Data were analyzed using JMP statistical software version 15 pro. RESULTS A total of 86 patients who met the criteria were included, 55 (64%) were males, with a mean age of 49.5+/-17.5 years. Antecedent infection was reported in 53 (61.6%), 51 (62.2%) presented within one week of symptoms onset. Ascending weakness was seen in 55 (70.5%), while 70 (81.4%) had areflexia. Acute motor axonal neuropathy (AMAN) was the commonest electrophysiological type of GBS in 41 (51.9%) patients. Albuminocytologic dissociation was seen in 48 (57%) who had lumbar puncture. Nearly half, 41 (47.7%) were admitted to the intensive care unit (ICU). Seventy (81.3%) were treated with intravenous immunoglobulin. There was no significant difference in the clinical presentation, management, ICU requirement, and discharge disposition between males and females. Females were more likely to have a higher disability at discharge (p=0.01). Patients younger than 60 years were more likely to require ICU admission (p=<0.01). CONCLUSION Our patients with GBS were slightly older than previously reported from the region. AMAN was the commonest type of GBS. Younger patients were more likely to need ICU admission, whereas females were more likely to have a more severe disability.
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Affiliation(s)
- Nada A AlKahtani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Joud A Alkhudair
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Nora Z Bensaeed
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Yara S Alshammari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Rahaf F Alanazi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Ismail A Khatri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Department of Neurology, King Abdullah International Medical Research Center, Riyadh, SAU
- Division of Neurology, Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU
| | - Nazish Masud
- Department of Biostatistics, Epidemiology and Environmental Health Sciences, Georgia Southern University, Statesboro, USA
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Singh A, Jain E, Sharma V, Sinha A, Khaliq W. Guillain-Barré Syndrome Presenting as Painful Weakness and Edema of the Legs: A Case Report. Cureus 2023; 15:e40641. [PMID: 37476105 PMCID: PMC10355341 DOI: 10.7759/cureus.40641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
Guillain-Barré syndrome (GBS) is an autoimmune inflammatory polyneuropathy, which can be challenging to diagnose due to variability in the initial presenting features. Pain, flaccid paresis, motor sensory disturbance, hyporeflexia, and autonomic dysfunction are the typical manifestations, although atypical features, such as ataxia, neck stiffness, dysphagia, ophthalmoplegia, bulbar palsy, and isolated upper limb weakness, may be seen. It may also progress to fatal respiratory depression. As such, timely diagnosis and treatment are essential. We present the case of a 41-year-old man who presented with a four-day history of acute-onset bilateral lower extremity swelling, decreased motor strength, diffuse muscle pain, hyporeflexia, and absent vibratory sensation. After admission, symptoms worsened, and the patient developed new-onset swallowing difficulty and urinary retention. Neurological examination findings of hyporeflexia and flaccid paralysis, along with normal thyroid function, and the absence of cord compression on spinal MRI pointed toward the diagnosis of GBS. Nerve conduction studies (NCS) and concentric electromyography (EMG) confirmed the diagnosis. The patient was treated with intravenous immune globulin (IVIG) and eventually discharged to a rehabilitation facility after a 12-day hospital stay. Later, the patient developed contractures and chronic pain consistent with post-GBS syndrome, for which we referred him for pain management and physical therapy. A rapidly progressive weakness with autonomic dysfunction should prompt suspicion of GBS and should be treated with intravenous immunoglobulins or plasma exchange without further delay.
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Affiliation(s)
- Amteshwar Singh
- Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Evani Jain
- Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Venus Sharma
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Amitasha Sinha
- Hospital Medicine, Beth Israel Deaconess Medical Center, Boston, USA
| | - Waseem Khaliq
- Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Zaki HA, Iftikhar H, Najam M, Masood M, Al-Marri NDR, Elgassim MAM, Fayed M, Shaban EE. Plasma exchange (PE) versus intravenous immunoglobulin (IVIG) for the treatment of Guillain-Barré syndrome (GBS) in patients with severe symptoms: A systematic review and meta-analysis. eNeurologicalSci 2023; 31:100468. [PMID: 37288440 PMCID: PMC10242495 DOI: 10.1016/j.ensci.2023.100468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 04/29/2023] [Accepted: 05/18/2023] [Indexed: 06/09/2023] Open
Abstract
Background and purpose Guillain- Barré syndrome (GBS) is a neuropathic condition that leads to the rapid development of impairments and is characterized by weakness and numbness or tingling sensation in the legs and arms and sometimes loss of movement and feeling in the legs, arms, upper body, and face. Currently, the cure for the disease is yet to be developed. However, treatment options such as intravenous immunoglobulin (IVIG) and plasma exchange (PE) have been used to minimize the symptoms and duration of the disease. Therefore, this systematic review and meta-analysis compared the efficacy of IVIG and PE in treating GBS patients with severe symptoms. Methodology Six electronic databases, including PubMed, Embase, Scopus, ScienceDirect, Medline, and Google scholar, were scoured for articles related and relevant to our research. Additionally, more studies were obtained through the reference lists of the studies retrieved from these electronic databases. Quality assessment and statistical data analysis were conducted using Review Manager software (RevMan 5.4.1). Results The search for relevant articles resulted in 3253 articles, of which only 20 were included for review in the current study. A sub-group analysis indicated no significant difference in the curative effect (Hughes score reduces by at least one score 4 weeks after GBS treatment; OR: 1.00; 95% CI: 0.66-1.52; p = 1.00 and Achieving grade 0 or 1 on Hughes scale; OR: 1.03; 95% CI: 0.27-3.94; p = 0.97). Similarly, the statistical showed that the difference in length of hospitalization and duration of mechanical ventilation was insignificant between the IVIG and PE group (Standard Mean Difference (SMD): -0.45; 95% CI: -0.92, 0.02; I2 = 91%; p = 0.06 and SMD: -0.54; 95% CI: -1.67, 0.59; I2 = 93%; p = 0.35, respectively). Moreover, the meta-analysis did not find any significant difference in the risk of GBS relapse (RR: 0.47; 95% CI: 0.20-1.14; p = 0.10) and risk of complications related to the treatment regimens (RR: 1.03; 95% CI: 0.71-1.48; p = 0.89). However, the statistical analysis of outcomes from 3 studies showed that the risk of discontinuation was significantly lower in the IVIG group than in the PE group (RR: 0.22; 95% CI: 0.06-0.88; p = 0.03). Conclusion Our study suggests that IVIG and PE have similar curative effects. Similarly, IVIG seems easier to use and thus can be preferred for treating GBS.
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Affiliation(s)
- Hany A. Zaki
- Emergency Medicine, Hamad General Hospital, P.O. Box 3050, Doha, Qatar
| | - Haris Iftikhar
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Mavia Najam
- Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
| | - Maarij Masood
- Emergency Medicine, Hamad General Hospital, P.O. Box 3050, Doha, Qatar
| | | | | | - Mohamed Fayed
- Emergency Medicine, Hamad General Hospital, P.O. Box 3050, Doha, Qatar
| | - Eman E. Shaban
- Cardiology, Al Jufairi Diagnosis and Treatment, Doha, Qatar
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Conway Morris A, Smielewska A. Viral infections in critical care: a narrative review. Anaesthesia 2023; 78:626-635. [PMID: 36633460 PMCID: PMC10952373 DOI: 10.1111/anae.15946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/13/2023]
Abstract
Viral infections form a substantial part of the intensive care workload, even before the recent and ongoing COVID-19 pandemic. The growing availability of molecular diagnostics for viral infections has led to increased recognition of these pathogens. This additional information, however, provides new challenges for interpretation and management. As the SARS-CoV-2 pandemic has amply demonstrated, the emergence and global spread of novel viruses are likely to provide continued challenges for critical care physicians into the future. This article will provide an overview of viral infections relevant to the critical care physician, discussing the diagnosis and management of respiratory viral infections, blood borne and enteric viruses. We will also discuss herpesviridae complications, commonly seen due to reactivation of latent infections. Further, we explore some rarer and emerging viruses, including recognition of viral haemorrhagic fevers, and briefly discuss post-viral syndromes which may present to the intensive care unit. Finally, we will discuss infection control and its importance in preventing nosocomial viral transmission.
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Affiliation(s)
- A. Conway Morris
- Division of Anaesthesia, Department of MedicineUniversity of CambridgeUK
- John V Farman Intensive Care UnitAddenbrooke's HospitalCambridgeUK
| | - A. Smielewska
- Department of Clinical Virology, LCL, CSSBLiverpool University Hospitals NHS Foundation TrustLiverpoolUK
- School of Clinical MedicineUniversity of LiverpoolUK
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14
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Neumeister J, Huang D, Dzluneski S, Huttleston AM, Megargel C, Falgiani M, Ganti L. Hyperacute and Fulminant Guillain-Barré Syndrome Requiring Emergent Intubation. Cureus 2023; 15:e38499. [PMID: 37273381 PMCID: PMC10237680 DOI: 10.7759/cureus.38499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/06/2023] Open
Abstract
Guillain-Barré syndrome (GBS) is an autoimmune-mediated acute polyneuropathy that can progress to life-threatening respiratory failure. The diagnosis and treatment of this pathology are complicated by the rarity of the disease and diversity in clinical presentation due to rarer, more dangerous subtypes of GBS. Understanding the time course of progression from onset to nadir of neurological deficits, maintaining a high index of suspicion, and close airway monitoring are essential in rapid diagnosis, securing the airway, and treatment.
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Affiliation(s)
| | - Derrick Huang
- Emergency Medicine, HCA Florida Ocala Hospital, Ocala, USA
| | | | | | | | - Michael Falgiani
- Emergency Medicine, HCA Florida Ocala Hospital, Ocala, USA
- Emergency Medicine, Envision Physician Services, Plantation, USA
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Latha Ganti
- Emergency Medicine, HCA Florida Ocala Hospital, Ocala, USA
- Emergency Medicine, Envision Physician Services, Plantation, USA
- Emergency Medicine, University of Central Florida College of Medicine, Orlando, USA
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15
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Rzymski P. Guillain-Barré syndrome and COVID-19 vaccines: focus on adenoviral vectors. Front Immunol 2023; 14:1183258. [PMID: 37180147 PMCID: PMC10169623 DOI: 10.3389/fimmu.2023.1183258] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
COVID-19 vaccination is a life-saving intervention. However, it does not come up without a risk of rare adverse events, which frequency varies between vaccines developed using different technological platforms. The increased risk of Guillain-Barré syndrome (GBS) has been reported for selected adenoviral vector vaccines but not for other vaccine types, including more widely used mRNA preparations. Therefore, it is unlikely that GBS results from the cross-reactivity of antibodies against the SARS-CoV-2 spike protein generated after the COVID-19 vaccination. This paper outlines two hypotheses according to which increased risk of GBS following adenoviral vaccination is due to (1) generation of anti-vector antibodies that may cross-react with proteins involved in biological processes related to myelin and axons, or (2) neuroinvasion of selected adenovirus vectors to the peripheral nervous system, infection of neurons and subsequent inflammation and neuropathies. The rationale behind these hypotheses is outlined, advocating further epidemiological and experimental research to verify them. This is particularly important given the ongoing interest in using adenoviruses in developing vaccines against various infectious diseases and cancer immunotherapeutics.
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Affiliation(s)
- Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan, Poland
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16
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Tran DH, Basra D, Bilgrami Z, Challa SR, Kwon C, Marciniak E, Verceles AC. Guillain-Barre syndrome secondary to COVID-19 infection: A case report. Clin Case Rep 2023; 11:e7104. [PMID: 37006840 PMCID: PMC10062311 DOI: 10.1002/ccr3.7104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/15/2023] [Accepted: 02/16/2023] [Indexed: 04/03/2023] Open
Abstract
Guillain-Barre syndrome (GBS) is a rare autoimmune disease that often manifests as a post-viral complication. However, its association with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. We present a rare case of GBS secondary to COVID-19 infection complicated by rapidly progressive sensorimotor deterioration resistant to plasma exchange therapy.
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Affiliation(s)
- Dena H. Tran
- Division of Pulmonary and Critical Care MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Dalwinder Basra
- Department of MedicineAmerican University of Antigua College of MedicineSaint JohnsAntigua and Barbuda
| | - Zaid Bilgrami
- Department of MedicineUniversity of Maryland Medical Center Midtown CampusBaltimoreMarylandUSA
| | - Suryanarayana R. Challa
- Department of MedicineUniversity of Maryland Medical Center Midtown CampusBaltimoreMarylandUSA
| | - Christina Kwon
- Department of MedicineUniversity of Maryland Medical Center Midtown CampusBaltimoreMarylandUSA
| | - Ellen Marciniak
- Division of Pulmonary and Critical Care MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Avelino C. Verceles
- Division of Pulmonary and Critical Care MedicineUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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17
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Msheik Z, El Massry M, Rovini A, Billet F, Desmoulière A. The macrophage: a key player in the pathophysiology of peripheral neuropathies. J Neuroinflammation 2022; 19:97. [PMID: 35429971 PMCID: PMC9013246 DOI: 10.1186/s12974-022-02454-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/29/2022] [Indexed: 12/22/2022] Open
Abstract
Macrophages are present in all mammalian tissues and coexist with various cell types in order to respond to different environmental cues. However, the role of these cells has been underestimated in the context of peripheral nerve damage. More importantly, macrophages display divergent characteristics, associated with their origin, and in response to the modulatory effects of their microenvironment. Interestingly, the advent of new techniques such as fate mapping and single-cell transcriptomics and their synergistic use has helped characterize in detail the origin and fate of tissue-resident macrophages in the peripheral nervous system (PNS). Furthermore, these techniques have allowed a better understanding of their functions from simple homeostatic supervisors to chief regulators in peripheral neuropathies. In this review, we summarize the latest knowledge about macrophage ontogeny, function and tissue identity, with a particular focus on PNS-associated cells, as well as their interaction with reactive oxygen species under physiological and pathological conditions. We then revisit the process of Wallerian degeneration, describing the events accompanying axon degeneration, Schwann cell activation and most importantly, macrophage recruitment to the site of injury. Finally, we review these processes in light of internal and external insults to peripheral nerves leading to peripheral neuropathies, the involvement of macrophages and the potential benefit of the targeting of specific macrophages for the alleviation of functional defects in the PNS.
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18
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Abstract
Neuroimmunological diseases and their treatment compromise the immune system, thereby increasing the risk of infections and serious illness. Consequently, vaccinations to protect against infections are an important part of the clinical management of these diseases. However, the wide variety of immunotherapies that are currently used to treat neuroimmunological disease — particularly multiple sclerosis and neuromyelitis optica spectrum disorders — can also impair immunological responses to vaccinations. In this Review, we discuss what is known about the effects of various immunotherapies on immunological responses to vaccines and what these effects mean for the safe and effective use of vaccines in patients with a neuroimmunological disease. The success of vaccination in patients receiving immunotherapy largely depends on the specific mode of action of the immunotherapy. To minimize the risk of infection when using immunotherapy, assessment of immune status and exclusion of underlying chronic infections before initiation of therapy are essential. Selection of the required vaccinations and leaving appropriate time intervals between vaccination and administration of immunotherapy can help to safeguard patients. We also discuss the rapidly evolving knowledge of how immunotherapies affect responses to SARS-CoV-2 vaccines and how these effects should influence the management of patients on these therapies during the COVID-19 pandemic. In this Review, the authors discuss how various immunotherapies for neuroimmunological diseases interact with vaccination responses, including responses to SARS-CoV-2 vaccinations, and the implications for the safe and effective use of vaccines in patients with these diseases. Vaccination against infection is an essential part of the management of neuroimmunological diseases. All indicated vaccinations should be administered before initiation of immunotherapy whenever possible; appropriate intervals between vaccination and treatment vary with treatment and vaccination. Inactivated vaccines are considered safe in neuroimmunological diseases but live vaccines are generally contraindicated during immunotherapy. Vaccination responses during immunotherapy can be diminished or abrogated, depending on the treatment and vaccination; antibody titre testing to monitor responses can be considered where appropriate. Vaccinations must be avoided during relapses or exacerbations of neuroimmunological diseases. Vaccination against SARS-CoV-2 is recommended for patients with neuroimmunological disease but some immunotherapies limit the immune response; therefore, timing should be considered carefully.
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19
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Beshir E, Belt E, Chencheri N, Saqib A, Pallavidino M, Terheggen U, Abdalla A, Herlitz L, Sharif E, Bitzan M. Case Report: Guillain-Barré Syndrome as Primary Presentation of Systemic Lupus Erythematosus (SLE-GBS) in a Teenage Girl. Front Pediatr 2022; 10:838927. [PMID: 35372162 PMCID: PMC8968442 DOI: 10.3389/fped.2022.838927] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/07/2022] [Indexed: 11/25/2022] Open
Abstract
Peripheral nervous system involvement accounts for fewer than 10% of SLE cases with neuropsychiatric manifestations. Guillain-Barré syndrome (GBS) as the presenting, major manifestation of pediatric SLE is extremely rare, and the best treatment approach is unknown. A 14-year-old, previously healthy female teenager developed classic features of GBS with ascending bilateral muscle weakness leading to respiratory insufficiency, associated with protein-cell dissociation in cerebro-spinal fluid, nerve root enhancement by MRI and reduction in compound muscle action potential amplitude. SLE was diagnosed serologically and histologically (lupus nephritis WHO class II). Despite immediate treatment with intravenous immunoglobulin (IVIg), methylprednisolone pulses and subsequently, rituximab, the patient required prolonged mechanical ventilation. She achieved full recovery following 14 PLEX treatments and two more rituximab infusions. Anti-dsDNA, C3, C4 and urinalysis normalized while anti-Smith and Sjögren antibodies persisted 15 months after disease onset, with no other lupus manifestations. Review of the literature revealed two pediatric cases of GBS at the onset of SLE and a third case with GBS 6 years after the diagnosis of SLE. Conventional GBS therapy may not be adequate to treat SLE-GBS. SLE should be included in the differential diagnosis of GBS. Importantly, treatment experiences and outcomes of such cases need be reported to inform future treatment recommendations.
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Affiliation(s)
- Elham Beshir
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates
| | - Ernestina Belt
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates
| | - Nidheesh Chencheri
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates
| | - Aqdas Saqib
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates
| | - Marco Pallavidino
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates.,College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Ulrich Terheggen
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates
| | - Abdalla Abdalla
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates
| | - Leal Herlitz
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, United States
| | - Elsadeg Sharif
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates
| | - Martin Bitzan
- Department of Paediatrics, Al Jalila Specialty Children's Hospital, Dubai, United Arab Emirates.,College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
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20
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Sutantoyo FF, Fadil, Basuki M, Fidiana, Hamdan M. Correlation Between Neutrophil-to-Lymphocyte Ratio and Motoric Deterioration in Patients With Guillain-Barre Syndrome. J Clin Neurol 2022; 18:671-680. [DOI: 10.3988/jcn.2022.18.6.671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/20/2022] [Accepted: 04/20/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Felisitas Farica Sutantoyo
- Department of Neurology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Fadil
- Department of Neurology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Mudjiani Basuki
- Department of Neurology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Fidiana
- Department of Neurology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Muhammad Hamdan
- Department of Neurology, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia
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21
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Laudanski K, Hajj J, Restrepo M, Siddiq K, Okeke T, Rader DJ. Dynamic Changes in Central and Peripheral Neuro-Injury vs. Neuroprotective Serum Markers in COVID-19 Are Modulated by Different Types of Anti-Viral Treatments but Do Not Affect the Incidence of Late and Early Strokes. Biomedicines 2021; 9:1791. [PMID: 34944606 PMCID: PMC8698659 DOI: 10.3390/biomedicines9121791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/15/2021] [Accepted: 11/19/2021] [Indexed: 01/07/2023] Open
Abstract
The balance between neurodegeneration, neuroinflammation, neuroprotection, and COVID-19-directed therapy may underly the heterogeneity of SARS-CoV-2's neurological outcomes. A total of 105 patients hospitalized with a diagnosis of COVID-19 had serum collected over a 6 month period to assess neuroinflammatory (MIF, CCL23, MCP-1), neuro-injury (NFL, NCAM-1), neurodegenerative (KLK6, τ, phospho τ, amyloids, TDP43, YKL40), and neuroprotective (clusterin, fetuin, TREM-2) proteins. These were compared to markers of nonspecific inflammatory responses (IL-6, D-dimer, CRP) and of the overall viral burden (spike protein). Data regarding treatment (steroids, convalescent plasma, remdasavir), pre-existing conditions, and incidences of strokes were collected. Amyloid β42, TDP43, NF-L, and KLK6 serum levels declined 2-3 days post-admission, yet recovered to admission baseline levels by 7 days. YKL-40 and NCAM-1 levels remained elevated over time, with clusters of differential responses identified among TREM-2, TDP43, and YKL40. Fetuin was elevated after the onset of COVID-19 while TREM-2 initially declined before significantly increasing over time. MIF serum level was increased 3-7 days after admission. Ferritin correlated with TDP-43 and KLK6. No treatment with remdesivir coincided with elevations in Amyloid-β40. A lack of convalescent plasma resulted in increased NCAM-1 and total tau, and steroidal treatments did not significantly affect any markers. A total of 11 incidences of stroke were registered up to six months after initial admission for COVID-19. Elevated D-dimer, platelet counts, IL-6, and leukopenia were observed. Variable MIF serum levels differentiated patients with CVA from those who did not have a stroke during the acute phase of COVID-19. This study demonstrated concomitant and opposite changes in neurodegenerative and neuroprotective markers persisting well into recovery.
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Affiliation(s)
- Krzysztof Laudanski
- The Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jihane Hajj
- School of Nursing, Widener University, Philadelphia, PA 19013, USA;
| | - Mariana Restrepo
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Kumal Siddiq
- College of Arts and Sciences, Drexel University, Philadelphia, PA 19104, USA;
| | - Tony Okeke
- School of Biomedical Engineering, Drexel University, Philadelphia, PA 19104, USA;
| | - Daniel J. Rader
- Department of Genetics, University of Pennsylvania, Philadelphia, PA 19104, USA;
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22
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Cao X, Tang M, Liu H, Yue X, Luo G, Yan Y. Case Report: Abnormal ECG and Pantalgia in a Patient With Guillain-Barré Syndrome. Front Cardiovasc Med 2021; 8:742740. [PMID: 34692793 PMCID: PMC8526714 DOI: 10.3389/fcvm.2021.742740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Guillain–Barré syndrome (GBS) is an acute immune-mediated disorder in the peripheral nervous system (PNS) characterized by symmetrical limb weakness, sensory disturbances, and clinically absent or decreased reflexes. Pantalgia and dysautonomia, including cardiovascular abnormalities, are common findings in the spectrum of GBS. It is usually challenging to distinguish GBS-related electrocardiogram (ECG) abnormities and chest pain from acute coronary syndrome (ACS) in patients with GBS due to the similar clinical symptom and ECG characteristics. Here, we present a case of GBS complicating ACS. Case Summary: A 37-year-old woman with a 2-month history of GBS presented to the emergency department due to pantalgia. The ECG showed a pattern of transitional T-wave inversion in the leads I, aVL, and V2 through V4 and shortly returned to normal, which appeared several times in a short time, but lab testing was unremarkable. Then, a further coronary computed tomography angiography (CTA) revealed the presence of critical stenosis of the left anterior descending artery, leading to the diagnosis of ACS. During the follow-up, she suffered from a non-ST-elevation myocardial infarction and accepted revascularization of the left anterior descending artery in the second week after discharge. Conclusion: Guillain–Barré syndrome could accompany chest pain and abnormalities on ECG. Meanwhile, it is essential to bear in mind that “GBS-related ECG abnormalities and chest pain” is a diagnosis of exclusion that can only be considered after excluding coronary artery disease, especially when concomitant chest pain, despite being a common presentation of pantalgia, occurs.
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Affiliation(s)
- Xiangqi Cao
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Manyun Tang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Hui Liu
- The Biobank of The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xin Yue
- Department of Cardiology, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, CA, United States
| | - Guogang Luo
- Stroke Centre and Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yang Yan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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23
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Rossetti A, Gheihman G, O'Hare M, Kosowsky JM. Guillain-Barré Syndrome Presenting as Facial Diplegia after COVID-19 Vaccination: A Case Report. J Emerg Med 2021; 61:e141-e145. [PMID: 34538679 PMCID: PMC8346349 DOI: 10.1016/j.jemermed.2021.07.062] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/25/2021] [Indexed: 01/01/2023]
Abstract
Background: Guillain-Barré Syndrome (GBS) is a rapidly progressive immune-mediated polyneuropathy often associated with an antecedent infectious illness or vaccination. The classic presentation of GBS is characterized by ascending limb weakness and numbness with loss of reflexes. However, atypical variants involving the face and arms or with purely sensory symptoms also exist. In up to 30% of cases, GBS progresses to respiratory failure, with patients requiring mechanical ventilation. Case Report: We report a case of atypical GBS occurring after Coronavirus disease 2019 (COVID-19) vaccination in an otherwise healthy 38-year-old man. The patient's clinical presentation was characterized by bilateral hand and foot paresthesias, dysarthria, bilateral facial weakness, and an absence of classic ascending limb weakness. Albuminocytological dissociation within the cerebrospinal fluid was suggestive of GBS. The patient received intravenous immunoglobulin therapy, with modest improvement in his symptoms at the time of his discharge from the hospital. Why Should an Emergency PhysicianBe Aware of This? Patients with GBS are at risk for life-threatening complications, including respiratory failure requiring mechanical ventilation. It is critical for emergency physicians to be aware of the manifold presentations of GBS for early recognition and treatment. This may be of particular importance in the context of a worldwide vaccination campaign in response to the COVID-19 pandemic.
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Affiliation(s)
| | - Galina Gheihman
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Meabh O'Hare
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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