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Warcup A, Movio G, Dhar S, Till C. Bickerstaff Brainstem Encephalitis Presenting With Negative Anti-GM1 and Anti-GQ1B Antibodies. Cureus 2024; 16:e61653. [PMID: 38966486 PMCID: PMC11223585 DOI: 10.7759/cureus.61653] [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: 06/04/2024] [Indexed: 07/06/2024] Open
Abstract
A woman in her 60s initially presented with rapid-onset left-sided hemiparesis with later development of slurred speech and left-sided facial droop. Despite ruling out common causes, her condition rapidly progressed with the development of bilateral proximal weakness, ophthalmoplegia, ataxia, and pyramidal signs eventually leading to a cardiorespiratory arrest. Extensive investigations, including computerised tomography (CT), magnetic resonance imaging (MRI), and lumbar puncture (LP), were negative for infectious or vascular aetiologies. Nerve conduction studies (NCS) revealed severe peripheral nerve damage, and despite a provisional diagnosis of Guillain-Barré Syndrome (GBS), the clinical picture aligned more with Bickerstaff Brainstem Encephalitis (BBE) given the central nervous system (CNS) involvement, despite negative anti-GM1 and anti-GQ1b autoantibodies. Treatment involved ventilatory support, immunoglobulins, and steroids. This case report describes a rare and challenging presentation of BBE and reminds clinicians to have a systematic approach to a patient presenting with rapid onset neurological symptoms and that BBE is a clinical diagnosis.
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Affiliation(s)
- Alice Warcup
- Medical Education, Lancaster Medical School, Lancaster, GBR
| | | | - Saikat Dhar
- Neurology, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, GBR
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Naresh K, Roy A, Srivastava S, Premkumar P, Nair A, Mani AM, Shaikh A, Thirumal PA, Sivadasan A, Mathew V, Premkumar PS, Benjamin R. Sensitivity and specificity of phrenic nerve electrophysiology to predict mechanical ventilation in the Guillain-Barré syndrome. Muscle Nerve 2023. [PMID: 37300403 DOI: 10.1002/mus.27918] [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: 07/20/2022] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION/AIMS In Guillain-Barré syndrome (GBS), the sensitivity and specificity of phrenic compound muscle action potential (CMAP) measurements to predict endotracheal mechanical ventilation are unknown. Hence, we sought to estimate sensitivity and specificity. METHODS We performed a 10-year retrospective analysis of adult GBS patients from our single-center laboratory database (2009 to 2019). The phrenic nerve amplitudes and latencies before ventilation were recorded along with other clinical and demographic features. Receiver operating curve (ROC) analysis with area under the curve (AUC) was used to determine the sensitivity and specificity with 95% confidence interval (CI) for phrenic amplitudes and latencies in predicting the need for mechanical ventilation. RESULTS Two hundred five phrenic nerves were analyzed in 105 patients. The mean age was 46.1 ± 16.2 years, with 60% of them being male. Fourteen patients (13.3%) required mechanical ventilation. The average phrenic amplitudes were lower in the ventilated group (P = .003), but average latencies did not differ (P = .133). ROC analysis confirmed that phrenic amplitudes could predict respiratory failure (AUC = 0.76; 95% CI, 0.61 to 0.91; P < .002), but phrenic latencies could not (AUC = 0.60; 95% CI, 0.46 to 0.73; P = .256). The best threshold for amplitude was ≥0.6 mV, with sensitivity, specificity, and positive and negative predictive values of 85.7%, 58.2%, 24.0%, and 96.4%, respectively. DISCUSSION Our study suggests that phrenic CMAP amplitudes can predict the need for mechanical ventilation in GBS. In contrast, phrenic CMAP latencies are not reliable. The high negative predictive value of phrenic CMAP amplitudes ≥0.6 mV can preclude mechanical ventilation, making these a useful adjunct to clinical decision-making.
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Affiliation(s)
- Kancha Naresh
- Neurology, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anupama Roy
- Neuro-Electrophysiology Laboratory, Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Shreya Srivastava
- Neuro-Electrophysiology Laboratory, Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Paul Premkumar
- Neuro-Electrophysiology Laboratory, Department of Neurosciences, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Aditya Nair
- Neurology, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Arun Mathai Mani
- Neurology, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Atif Shaikh
- Neurology, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Ajith Sivadasan
- Neurology, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Neurology, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Rohit Benjamin
- Neurology, Department of Neurosciences, Christian Medical College, Vellore, Tamil Nadu, India
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Leung C. A lesson learnt from the emergence of Zika virus: What flaviviruses can trigger Guillain-Barré syndrome? J Med Virol 2020; 92:2938-2945. [PMID: 32077499 DOI: 10.1002/jmv.25717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/13/2020] [Indexed: 01/06/2023]
Abstract
While Zika virus outbreaks raised the concern about rare viral infections in human, attention should also be paid to other Guillain-Barré syndrome (GBS) inducing viruses. This study aims to search for other flaviviruses likely to be associated with GBS. Amino acid (aa) sequence matching analysis was conducted to identify viruses molecularly similar to the Zika virus and human GBS-related proteins. A systematic review of clinical literature was performed to summarize the clinical findings of the GBS-associated flaviviruses identified in the aa sequence matching analysis. It was found that more than 10 pentapeptides were shared between 9 flaviviruses, Zika virus, and human GBS-related proteins. Twenty-six articles totaling 42 clinical cases were eligible for inclusion in the systematic review concerning the nine flaviviruses identified. While some patients showed signs of encephalitis, 5 out of 42 cases demonstrated typical GBS symptoms. Public health professionals should be aware of other GBS-associated flaviviruses and GBS cases with mild symptoms.
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Affiliation(s)
- Char Leung
- Deakin University, Burwood, Victoria, Australia
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Kajumba MM, Kolls BJ, Koltai DC, Kaddumukasa M, Kaddumukasa M, Laskowitz DT. COVID-19-Associated Guillain-Barre Syndrome: Atypical Para-infectious Profile, Symptom Overlap, and Increased Risk of Severe Neurological Complications. ACTA ACUST UNITED AC 2020; 2:2702-2714. [PMID: 33251483 PMCID: PMC7680081 DOI: 10.1007/s42399-020-00646-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
The concurrence of COVID-19 with Guillain-Barre syndrome (GBS) can increase the likelihood of neuromuscular respiratory failure, autonomic dysfunction, and other life-threatening symptoms. Currently, very little is known about the underlying mechanisms, clinical course, and prognostic implications of comorbid COVID-19 in patients with GBS. We reviewed COVID-19-associated GBS case reports published since the outbreak of the pandemic, with a database search up to August 2020, including a manual search of the reference lists for additional relevant cases. Fifty-one (51) case reports of COVID-19 patients (aged 23–84 years) diagnosed with GBS in 11 different countries were included in this review. The results revealed atypical manifestations of GBS, including para-infectious profiles and onset of GBS without antecedent COVID-19 symptoms. Although all tested patients had signs of neuroinflammation, none had SARS-CoV-2 in the cerebrospinal fluid (CSF), and only four (4) patients had antiganglioside antibodies. The majority had a 1- to 10-day time interval between the onset of COVID-19 and GBS symptoms, and many had a poor outcome, with 20 out of the 51 (39.2%) requiring mechanical ventilation, and two deaths within 12 to 24 h. The atypical manifestations of COVID-19-associated GBS, especially the para-infectious profile and short time interval between the onset of the COVID-19 and GBS symptoms, increase the likelihood of symptom overlap, which can complicate the treatment and result in worsened disease progression and/or higher mortality rates. Inclusion of a neurological assessment during diagnosis of COVID-19 might facilitate timely identification and effective management of the GBS symptoms and improve treatment outcome.
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Affiliation(s)
- Mayanja M. Kajumba
- Department of Mental Health and Community Psychology, School of Psychology, Makerere University, P. O. Box, 7062 Kampala, Uganda
| | - Brad J. Kolls
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC 27705 USA
- Department of Neurology, Duke University School of Medicine, Durham, NC USA
- Neuroscience Medicine, Duke Clinical Research Institute, 300 W Morgan St, Durham, NC 27701 USA
| | - Deborah C. Koltai
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC 27705 USA
- Department of Neurology, Duke University School of Medicine, Durham, NC USA
- Department of Psychiatry and Behavioral Sciences, DUMC, Duke University School of Medicine, Box 3119, Trent Drive, Durham, NC USA
| | - Mark Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Martin Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Daniel T. Laskowitz
- Duke Division of Global Neurosurgery and Neurology, Department of Neurosurgery, Duke University Medical Center, Box 3807, Durham, NC 27705 USA
- Department of Neurology, Duke University School of Medicine, Durham, NC USA
- Neuroscience Medicine, Duke Clinical Research Institute, 300 W Morgan St, Durham, NC 27701 USA
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