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López-Hernández JC, Vargas-Cañas ES, Galnares-Olalde JA, López-Alderete JA, López-Pizano A, Rivas-Cruz MA, Violante-Villanueva JA, Paredes-Aragón E. Factors Predicting Prolonged Mechanical Ventilation in Guillain-Barré Syndrome. Can J Neurol Sci 2024; 51:98-103. [PMID: 36788667 DOI: 10.1017/cjn.2023.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Up to 30% of patients with Guillain-Barré syndrome require mechanical ventilation and 5% die due to acute complications of mechanical ventilation. There is a considerable group of patients that will need prolonged mechanical ventilation (considered as >14 days) and should be considered for early tracheostomy. The objective of this study is to identify risk factors for prolonged mechanical ventilation. METHODS We prospectively analyzed patients with Guillain-Barré diagnosis with versus without prolonged mechanical ventilation. We considered clinical and electrophysiological characteristics and analyzed factors associated with prolonged mechanical ventilation. RESULTS Three hundred and three patients were included; 29% required mechanical ventilation. When comparing the groups, patients with prolonged invasive mechanical ventilation (IMV) have a lower score on the Medical Research Council score (19.5 ± 16.2 vs 27.4 ± 17.5, p = 0.03) and a higher frequency of dysautonomia (42.3% vs 19.4%, p = 0.037), as well as lower amplitudes of the distal compound muscle action potential (CMAP) of the median nerve [0.37 (RIQ 0.07-2.25) vs. 3.9 (RIQ1.2-6.4), p = <0.001] and ulnar nerve [0.37 (RIQ0.0-3.72) vs 1.5 (RIQ0.3-6.6), p = <0.001], and higher frequency of severe axonal damage in these nerves (distal CMAP ≤ 1.0 mV). Through binary logistic regression, severe axonal degeneration of the median nerve is an independent risk factor for prolonged IMV OR 4.9 (95%CI 1.1-21.5) p = 0.03, AUC of 0.774, (95%CI 0.66-0.88), p = < 0.001. CONCLUSIONS Severe median nerve damage is an independent risk factor for prolonged mechanical ventilation.
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Affiliation(s)
- Juan Carlos López-Hernández
- Neuromuscular Diseases Department, Instituto Nacional de Neurología y Neurocirugía, Mexico
- Neurologic Emergencies Department, Instituto Nacional de Neurología y Neurocirugía, Mexico
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López-Hernández JC, Jorge de Saráchaga A, Briseño-Godínez ME, May-Mas RN, Bazán-Rodríguez L, León-Manriquez E, Cruz-Pérez J, Becerra-Hernández I, Vargas-Cañas ES. Deltoid muscle strength and autonomic dysfunction as independent risk factors for invasive mechanical ventilation in patients with Guillain-Barré syndrome. Int J Neurosci 2023; 133:1403-1410. [PMID: 35633066 DOI: 10.1080/00207454.2022.2082963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 05/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Almost a third of patients with Guillain-Barré Syndrome (GBS) require mechanical ventilation, increasing mortality by 15-30% and proving poor functional outcomes. The Erasmus GBS Respiratory Insufficiency Score (EGRIS) is the most frequently used scale to assess probability of respiratory insufficiency within the first week of admission. We aim to determine other clinical and electrophysiological prognostic factors for invasive mechanical ventilation (IMV) in patients with GBS. MATERIAL AND METHODS A cross-sectional ambispective cohort study was carried out in a referral center in Mexico City, from January 2015 to December 2019. Baseline demographics, MRC score, Hughes scale, EGRIS, dysautonomia and nerve conduction studies were performed on admission in GBS patients that required IMV. A multivariable analysis for IMV and a survival analysis for independent walk in prolonged-IMV (>14 days) were performed. RESULTS Forty-nine (32%) out of 153 GBS patients required IMV. Statistically significant prognostic factors in multivariable analysis were deltoid muscle strength ≤2 [OR 7.1 (1.6-31.1)], EGRIS [OR 2.5 (1.3-4.6)] and autonomic dysfunction [OR 6.6 (2.0-22.0)]. Electrodecrement <1 mV in the compound muscle action potential (CMAP) of distal motor median nerve was more prevalent in prolonged-IMV patients (44.8% vs. 21%, p = .049). A significant minor prevalence of prolonged-IMV patients regain independent walk at 6 months using the Kaplan-Meier method (log rank test p < .001). CONCLUSIONS We provide new specific clinical (deltoid muscle strength and autonomic dysfunction) and electrophysiological variables to discriminate GBS patients that will require IMV.
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Affiliation(s)
| | - Adib Jorge de Saráchaga
- Neuromuscular Disorders Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Raúl Nathanael May-Mas
- Neuromuscular Disorders Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Lisette Bazán-Rodríguez
- Neuromuscular Disorders Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Elizabeth León-Manriquez
- Neuromuscular Disorders Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Jocelyn Cruz-Pérez
- Neurocritical Care Department, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Israel Becerra-Hernández
- Neurocritical Care Department, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Edwin Steven Vargas-Cañas
- Neuromuscular Disorders Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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Vargas-Cañas ES, Galnares-Olalde JA, León-Velasco F, García-Grimshaw M, Gutiérrez A, López-Hernández JC. Prognostic Implications of Early Albuminocytological Dissociation in Guillain-Barré Syndrome. Can J Neurol Sci 2023; 50:745-750. [PMID: 35979659 DOI: 10.1017/cjn.2022.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Half of Guillain-Barré syndrome (GBS) present elevated cerebrospinal fluid (CSF) protein levels within 1 week since symptom onset and 80% within 2 weeks. Our objective was to determine the clinical and prognostic implication of albuminocytological dissociation in early GBS. METHODS An ambispective cohort study was conducted. Good outcome was considered if the patient was able to walk unaided (Guillain-Barré disability score [GDS] ≤ 2 points) at 3-month follow-up. Patients were classified into two groups: with and without albuminocytological dissociation; we compared clinical and paraclinic characteristics between the groups. We analyzed clinical and electrophysiological factors related to presenting early dissociation through a multivariate model. RESULTS We included 240 patients who fulfilled Asbury criteria for GBS. On further selection, only 94 patients fulfilled inclusion. Mean age was 45.94 ± 17.1 years and 67% were male. Median time from symptom onset to admission was 5 days (IQR 3-6). Regarding albuminocytological dissociation and electrophysiological variants, we found a significant difference: acute inflammatory demyelinating polyneuropathy (AIDP) [60.6% vs 26.2%, p = 0.002], acute motor axonal neuropathy (AMAN) [21.2% vs 49.1%, p = 0.009] and acute motor sensory axonal neuropathy (AMSAN) [12.1% vs 1.6%, p = 0.05]. We did not observe significant differences in recovery of independent walking in short term between both groups. The presence of conduction block in any variant (OR 3.21, 95% CI 1.12-9.16, p = 0.02) and absence of sural registration (OR 5.69, 95% CI 1.48-21.83, p = 0.011) were independent factors related to early dissociation. CONCLUSIONS Early dissociation (<7 days) is not associated with any particular clinical feature or unfavorable outcome. It is more common to see in AIDP rather than axonal variants.
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Affiliation(s)
- Edwin Steven Vargas-Cañas
- Neuromuscular diseases Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Javier Andrés Galnares-Olalde
- Neuromuscular diseases Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Fausto León-Velasco
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Miguel García-Grimshaw
- Neurology Department, Neurology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Alonso Gutiérrez
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Juan Carlos López-Hernández
- Neuromuscular diseases Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
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Kazakova E, Téllez-Martínez JA, Flores-Lagunes L, Sosa-Ortiz AL, Carillo-Sánchez K, Molina-Garay C, González-Domínguez CA, Jimenez-Olivares M, Fernandez-Valverde F, Vargas-Cañas ES, Vázquez-Memije ME, Garcia-Latorre EA, Martínez-Duncker I, Alaez-Verson C. Uterus infantilis: a novel phenotype associated with AARS2 new genetic variants. A case report. Front Neurol 2023; 14:878446. [PMID: 37456626 PMCID: PMC10343430 DOI: 10.3389/fneur.2023.878446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/10/2023] [Indexed: 07/18/2023] Open
Abstract
Objectives To report the first Mexican case with two novel AARS2 mutations causing primary ovarian failure, uterus infantilis, and early-onset dementia secondary to leukoencephalopathy. Methods Detailed clinical, clinimetric, neuroimaging features, muscle biopsy with biochemical assays of the main oxidative phosphorylation complexes activities, and molecular studies were performed on samples from a Mexican female. Results We present a 41-year-old female patient with learning difficulties since childhood and primary amenorrhea who developed severe cognitive, motor, and behavioral impairment in early adulthood. Neuroimaging studies revealed frontal leukoencephalopathy with hypometabolism at the fronto-cerebellar cortex and caudate nucleus. Uterus infantilis was detected on ultrasound study. Clinical exome sequencing identified two novel variants, NM_020745:c.2864G>A (p.W955*) and NM_020745:c.1036C>A (p.P346T, p.P346Wfs*18), in AARS2. Histopathological and biochemical studies on muscle biopsy revealed mitochondrial disorder with cytochrome C oxidase (COX) deficiency. Conclusions Several adult-onset cases of leukoencephalopathy and ovarian failure associated with AARS2 variants have been reported. To our best knowledge, none of them showed uterus infantilis. Here we enlarge the genetic and phenotypic spectrum of AARS2-related dementia with leukoencephalopathy and ovarian failure and contribute with detailed clinical, clinometric, neuroimaging, and molecular studies to disease and novel molecular variants characterization.
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Affiliation(s)
- Ekaterina Kazakova
- Centro de Diagnóstico en Metabolismo Energético y Medicina Mitocondrial, Mexico City, Mexico
| | - José Alberto Téllez-Martínez
- Clínica de Cognición, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Leonardo Flores-Lagunes
- Laboratorio de Diagnóstico Genómico, Instituto Nacional de Medicina Genómica, Mexico City, Mexico
| | - Ana Luisa Sosa-Ortiz
- Clínica de Cognición, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Karol Carillo-Sánchez
- Laboratorio de Diagnóstico Genómico, Instituto Nacional de Medicina Genómica, Mexico City, Mexico
| | - Carolina Molina-Garay
- Laboratorio de Diagnóstico Genómico, Instituto Nacional de Medicina Genómica, Mexico City, Mexico
| | - Carlos Alberto González-Domínguez
- Laboratorio de Glicobiología Humana y Diagnóstico Molecular, Centro de Investigación en Dinámica Celular, Instituto de Investigación en Ciencias Básicas y Aplicadas, Universidad Autónoma del Estado de Morelos, Morelos, Mexico
| | - Marco Jimenez-Olivares
- Laboratorio de Diagnóstico Genómico, Instituto Nacional de Medicina Genómica, Mexico City, Mexico
| | - Francisca Fernandez-Valverde
- Laboratorio de Patología Experimental, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Edwin Steven Vargas-Cañas
- Clínica de Nervio y Músculo, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | | | | | - Iván Martínez-Duncker
- Laboratorio de Glicobiología Humana y Diagnóstico Molecular, Centro de Investigación en Dinámica Celular, Instituto de Investigación en Ciencias Básicas y Aplicadas, Universidad Autónoma del Estado de Morelos, Morelos, Mexico
| | - Carmen Alaez-Verson
- Laboratorio de Diagnóstico Genómico, Instituto Nacional de Medicina Genómica, Mexico City, Mexico
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López-Hernández JC, Rivas-Cruz MA, Galnares-Olalde JA, López-Alderete JA, López-Pizano A, Alcalá RE, Villanueva AV, Vargas-Cañas ES. Sural nerve involvement in Guillain-Barré syndrome: Clinical and prognostic implications. A prospective cohort. J Clin Neurosci 2023; 110:48-52. [PMID: 36791495 DOI: 10.1016/j.jocn.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 12/08/2022] [Accepted: 01/04/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Sural sparing is common in Guillain-Barré syndrome (GBS). However, one third of patients have sural nerve compromise. Its clinical implications associated factors and short-term prognosis are still unknown. The objective of this study is to identify if sural nerve compromise is associated with a worse prognosis and to describe clinical and electrophysiological characteristics in Guillain-Barré syndrome. MATERIALS AND METHODS We prospectively analyzed patients with Guillain-Barré diagnosis with vs without sural nerve compromise. All patients underwent nerve conduction studies within the first 3 days of hospital admission. Clinical and electrophysiological characteristics were compared between groups. RESULTS 174 patients were included in this study. Acute inflammatory demyelinating polyneuropathy was the predominant variant (43.7 %). Thirty percent of patients had sural nerve involvement. In the comparative analysis between affected vs unaffected sural groups, age ≥50 years and Guillain-Barré disability score ≥3 demonstrated a statistically significant difference. Regarding short-term recovery period for independent walking, there was no significant difference. In the multivariate analysis, age ≥50 years was identified as independent factors for sural nerve compromise on admission. CONCLUSION sural nerve compromise occurs in 30 % of patients with GBS and is not associated with a worse functional prognosis. Age ≥50 years was identified as an independent factor for sural nerve compromise.
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Affiliation(s)
- Juan Carlos López-Hernández
- Neuromuscular Diseases Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico.
| | - Mijail Adán Rivas-Cruz
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico
| | | | | | - Alejandro López-Pizano
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico
| | - Raúl E Alcalá
- Neurology Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico
| | | | - Edwin Steven Vargas-Cañas
- Neuromuscular Diseases Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico
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Escamilla-Ramírez A, López-Hernández JC, Díaz-Martínez R, Galnares-Olalde J, Vargas-Cañas ES. [Clinical and neurophysiological patterns of early presenting symptoms in acute onset chronic inflammatory demyelinating polyradiculoneuropathy]. Rev Neurol 2022; 75:341-347. [PMID: 36440746 DOI: 10.33588/rn.7511.2022243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The phenotypes of chronic inflammatory demyelinating polyneuropathy (CIDP) include an acute-onset phenotype (A-CIDP) with an evolution time of less than eight weeks from the onset of symptoms. This entity can be confused with Guillain-Barre syndrome of the acute inflammatory demyelinating variety (AIDP), delaying the start of treatment. OBJECTIVE To analyze the clinical and electrophysiological differences between A-CIDP, classic CIDP and AIDP, in order to identify factors that may help in the early differential diagnosis. PATIENTS AND METHODS A cross-sectional study was carried out with patients seen at the neuromuscular disease clinic of the National Institute of Neurology and Neurosurgery with a diagnosis of CIDP according to the criteria of the European Federation of Neurological Societies and Peripheral Nerve Society. Patients with CIDP <8 weeks were categorized as A-CIDP and were compared with patients diagnosed with classic CIDP and AIDP. Clinical, paraclinical and electrophysiological variables were obtained and analyzed. RESULTS Significant differences in history of infection, cranial nerve involvement and dysautonomia were observed between A-CIDP and AIDP. Electrophysiological recordings reported significant differences in motor nerve conduction velocity and sural nerve recordings, being lower in the A-CIDP group. CONCLUSION A history of infection, cranial nerve involvement and dysautonomia are important parameters to take into account for the differential diagnosis of these entities. Electrophysiological analysis is similar between A-CIDP and CIDP. The differential diagnosis between these types of demyelinating polyneuropathy must be based on clinical assessment.
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Affiliation(s)
| | - J C López-Hernández
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México.,Clínica de Enfermedades Neuromusculares, Ciudad de México, México
| | - R Díaz-Martínez
- Clínica de Enfermedades Neuromusculares, Ciudad de México, México
| | - J Galnares-Olalde
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - E S Vargas-Cañas
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
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López-Hernández JC, Galnares-Olalde JA, Gutiérrez A, Estrada SA, García-Grimshaw M, Vargas-Cañas ES. Guillain-Barre syndrome in Mexico: clinical features and validation of Brighton Collaboration Group criteria. Rev Neurol 2022; 74:258-264. [PMID: 35383873 DOI: 10.33588/rn.7408.2021437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION As SARS-CoV-2 vaccination is ongoing in Mexico and Guillain-Barre syndrome (GBS) cases have been reported, validation of Brighton criteria in Mexico is necessary. Moreover, epidemiology of GBS in Mexico differs from European and North American countries. OBJECTIVE To describe the clinical, cerebrospinal and electrodiagnostic features in Mexican patients diagnosed with GBS and classify them according to the Brighton Collaboration Group diagnostic criteria. Patrients and methods. An ambispective cohort study was conducted. We included patients that fulfilled the National Institute of Neurological Disorders and Stroke (NINDS) diagnostic criteria for Guillain-Barre syndrome. Patients in this study were classified according to Brighton collaboration group levels of certainty for Guillain-Barre syndrome. RESULTS Sixty eight percent of patients were male. Of the 248 patients included, 58.4% had history of a precedent infection, mean time from symptom onset to admission was 5 (1-30) days. Mean Medical Research Council sum score 30.3 ± 15.5. Almost 98% of patients had a monophasic course. Level 1 of certainty according to Brighton collaboration group criteria was fulfilled by 54.6% of patients, level 2 by 45% and level 4 by 0.6%. Patients meeting level 2 of certainty were mostly because normal cerebrospinal fluid findings or findings in nerve conduction studies not consistent with any GBS variants. CONCLUSION GBS is a frequent autoimmune neuropathy that has been associated with preceding infections and with vaccination campaigns. For SARS-CoV-2 vaccination campaign in Mexico, validation of Brighton Criteria is necessary. Although Mexico's GBS epidemiology has been changing throughout recent years, this study provides similar data compared to other countries.
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Affiliation(s)
- J C López-Hernández
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - J A Galnares-Olalde
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - A Gutiérrez
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - S A Estrada
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - M García-Grimshaw
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - E S Vargas-Cañas
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
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López-Hernández JC, Briseño-Godinez ME, Pérez-Valdez EY, May-Mas RN, Galnares-Olalde JA, Martínez-Angeles V, Ramírez-Bermudez J, León-Manriquez E, Chavira-Hernández G, Vargas-Cañas ES. Inpatient Delirium in Guillain-Barré Syndrome: Frequency and Clinical Characteristics in a Mexican Hospital. Cureus 2021; 13:e19260. [PMID: 34900457 PMCID: PMC8648133 DOI: 10.7759/cureus.19260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background Delirium has a prevalence of 14%-56% in hospitalized patients. Risk factors include advanced age, invasive mechanical ventilation (IMV), and prolonged intensive care unit stay. Neuropsychiatric symptoms have been reported to be related to autoimmune responses secondary to Guillain-Barré syndrome (GBS) with direct involvement of the central nervous system (CNS) or to delirium. There are few reports of the frequency of delirium in patients with Guillain-Barré syndrome (GBS). Objective To describe the frequency of and the characteristics associated with delirium in patients with GBS. Material and methods A single-center, cross-sectional study was conducted in patients with GBS diagnosis between 2015 and 2019. The diagnosis of delirium was made using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria. We compared patients with and without delirium. We performed both univariate and multivariate analyses to identify factors associated with delirium. Results A total of 154 patients with GBS were included, of which 20 (12.9%) fulfilled the DSM-5 criteria for delirium. The mean age was 48 ± 18.2 years, the median Medical Research Council (MRC) sum score was 29.3 ± 21.9 points, 65% had bulbar cranial nerve involvement, 80% presented autonomic dysfunction, 85% had ICU stay, and 90% had mechanical ventilation requirement. In the multivariate analysis, the following were the independent factors for the development of delirium: age ≥ 60 (odds ratio (OR): 5.7; 95% confidence interval (CI): 1.3-23.5), time from symptom onset to admission ≤ 3 days (OR: 4.3; 95% CI: 1.1-16.8), autonomic dysfunction (OR: 13.1; 95% CI: 3-56), and intensive care unit stay (OR: 9.5; 95% CI: 2.1-42.6). Conclusion Delirium is not frequent in patients with Guillain-Barré syndrome. Patients with advanced age, rapid motor progression, bulbar cranial nerve involvement, prolonged intensive care unit stay, and mechanical ventilation need are more likely to present delirium.
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Affiliation(s)
- Juan Carlos López-Hernández
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Maria E Briseño-Godinez
- Neurology, Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suárez, Mexico City, MEX
| | - Esther Y Pérez-Valdez
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Raul N May-Mas
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Javier A Galnares-Olalde
- Neurology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Victoria Martínez-Angeles
- Neuropsychiatry, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Jesus Ramírez-Bermudez
- Neuropsychiatry, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Elizabeth León-Manriquez
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | | | - Edwin Steven Vargas-Cañas
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
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López-Hernández JC, Pérez-Valdez EY, León-Manríquez E, Bazán-Rodríguez L, Galnares-Olalde JA, Jorge-de Saráchaga A, Briseño-Godínez ME, May-Mas RN, Vargas-Cañas ES. Guillain-Barre syndrome during COVID-19 pandemic: experience from a referral healthcare center in Mexico. Rev Neurol 2021; 73:315-320. [PMID: 34676529 DOI: 10.33588/rn.7309.2021364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION To describe clinical characteristics and electrophysiological variants of GBS cases during the pandemic, we carried out a comparative analysis between SARS-CoV2 related GBS and non-SARS-CoV2 patients and then compared to the 2019 cases. PATIENTS AND METHODS We carried out a cross-sectional study of GBS patients diagnosed according to Asbury and Cornblath criteria. We collected information on clinical and paraclinical variables. We defined a SARS-CoV-2 related GBS case according to the description of Ellul et al. We used Hadden criteria to classify the electrophysiological variants. We performed a comparative analysis between groups. RESULTS Fourty-two patients were diagnosed with GBS in 2020, men 64.2%, age 46 ± 17.4 years, patients with obesity/overweight 42.8%, previous diarrhea 31%, history of respiratory tract infection 14.2%. Guillain Barre Disability Scale = 3 points 71.4% and, cranial nerve involvement 69%. The most frequent electrophysiological variant was acute inflammatory demyelinating polyradiculoneuropathy (AIDP) 53.5%. Seven (16.6%) cases were SARS-CoV2 related, four men, age 43.4 ± 13.4 years. When comparing patients with GBS in 2020 vs patients in 2019, we observed a decrease in the previous infection history during 2020 (45.2% vs 73.3%, p-value = 0.005) and a decrease in previous respiratory infection (14.2% vs 33.3%, p = 0.045), as well as a higher frequency of cranial nerve involvement, and albuminocytologic dissociation. CONCLUSIONS SARS-CoV2 virus infection preventive measures may be impacting the presentation of post-infectious diseases such as GBS. We did not observe an increase in GBS cases during 2020. Also, the AIDP variant were more frequent in our population in the COVID-19 pandemic.
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Affiliation(s)
| | - E Y Pérez-Valdez
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - E León-Manríquez
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - L Bazán-Rodríguez
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | | | | | - R N May-Mas
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - E S Vargas-Cañas
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
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López-Hernández JC, Mercado-Pompa A, Pérez-Torres T, Galnares-Olalde JA, Vargas-Cañas ES. Efficacy of long-term prednisone therapy in patients with chronic inflammatory demyelinating polyneuropathy (CIDP): a retrospective cohort study. Rev Neurol 2021; 73:275-281. [PMID: 34617581 DOI: 10.33588/rn.7308.2021261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Patients with CIDP respond adequately to steroid therapy and intravenous immunoglobulin (IVIG). However, few patients have access to IVIG in developing countries. Little information exists about the clinical response to steroid therapy in Latin American countries. OBJECTIVE to describe the long-term functional clinical response (24 months) to prednisone therapy in CIDP patients. MATERIAL AND METHODS A retrospective cohort was conducted. Selection included patients with definitive CIDP diagnosis according to European criteria from the Neuromuscular Diseases clinic of the National Institute of Neurology and Neurosurgery between January 2016 and December 2020. Good response to steroid therapy was defined as with improvement in at least one point on the GBS disability score. Poor response to steroid therapy was defined as patients who did not show improvement in at least one point on the GBS disability score. Patients were evaluated at 3, 6, 12, 18 and 24 months. RESULTS Forty-seven patients with CIDP were included. Half of them were male and mean age was 46±15 years. Mean time since symptom onset to diagnosis was 6 (IQR 2-12) months. The most common clinical variant was sensory-motor 57.4%, followed by acute-onset CIDP 21.3% and atypical variants 21.2%. At diagnosis our patients presented: mean GBS disability score of 3 (2.25-4) points, MRC score 39.5 ± 12 points, independent gait in 17%, mean prednisone dose of 50 mg (32.5-50). Twenty-four months after prednisone therapy, a less mean GBS disability score -1(0-2) points-, mean MRC score 56.3 ± 5.1 points, independent gait 93% and prednisone dose 1 (0-5) mg. Patients with poor three-month functional clinical response had a delay in diagnosis > 6 months (64.7% vs 27.5%) and atypical clinical variants (47% vs 6.8%). CONCLUSION CIDP patients treated with prednisone have good long-term functional clinical response. Delay in diagnosis and atypical variant are common clinical characteristics for poor functional clinical response in treatment with prednisone.
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Affiliation(s)
| | - A Mercado-Pompa
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | - T Pérez-Torres
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | - E S Vargas-Cañas
- Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
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López-Hernández JC, Galnares-Olalde JA, Benitez-Alonso E, Alcalá RE, Vargas-Cañas ES. Vacuolar Myopathy Associated to CACNA1S Mutation as a Rare Cause of Late-Onset Limb-Girdle Myopathy: A Case Report. Cureus 2021; 13:e18873. [PMID: 34804722 PMCID: PMC8599111 DOI: 10.7759/cureus.18873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 11/05/2022] Open
Abstract
Late-onset limb-girdle myopathies pose a diagnostic challenge. The most common etiologies are inflammatory, followed by genetic and metabolic. Rare cases include limb-girdle dystrophies and permanent myopathies (vacuolar), such as those associated with hypokalemic periodic paralysis (HypoPP). We present the case of a 59-year-old male who initiated with episodic acute severe weakness when he was 11, during which serum potassium levels of <2.5 meq/L were revealed during workup. Potassium reposition reversed these episodes. They occurred every three to five years, and the last episode was five years prior to the current illness. When he was 58, he presented progressive pelvic girdle weakness. On examination, he presented decreased strength in the iliopsoas and quadriceps. The laboratory results showed mildly elevated creatine kinase. Muscle biopsy revealed a vacuolar myopathy, and genetic testing identified a pathogenic variant in the CACNA1S gene, locus 1q32.1 [c.3716G> A (p.Arg1239His), heterozygous state].
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Affiliation(s)
- Juan Carlos López-Hernández
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Javier A Galnares-Olalde
- Neurology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Edmar Benitez-Alonso
- Neurogenetics Department, Instituto Nacional de Neurología y Neurocirugía, Mexico City, MEX
| | - Raul E Alcalá
- Neuromuscular Disease Department, Instituto Nacional de Neurología y Neurocirugía, Mexico City, MEX
| | - Edwin Steven Vargas-Cañas
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
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12
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Briseño-Godínez ME, Arauz A, López-Hernández JC, de Saráchaga AJ, Pérez-Valdez EY, May-Más RN, López-Hernández G, Bazán-Rodriguez L, Galnares-Olalde JA, León-Manríquez E, Vargas-Cañas ES. Prognostic Factors in Elderly Patients With Guillain-Barré Syndrome: Does Age Matter? Neurohospitalist 2021; 11:303-309. [PMID: 34567390 DOI: 10.1177/19418744211002676] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction Twenty to 40% of Guillain Barré syndrome (GBS) patients will not be able to walk independently despite effective treatment. Older patients carry additional risks for worse outcomes. Methods A single center, ambispective cohort study was performed. Only subjects ≥18 years with a 3-month follow-up were included. Elderly patients were considered as a whole if ≥ 60 years. Demographics, CSF and nerve conduction studies were compared. A binomial logistic regression and Kaplan-Meier analyses were carried out to estimate good prognosis (Hugues ≤2) at 3-month follow-up. Results From 130 patients recruited, 27.6% were elderly adults. They had a more severe disease, higher mEGOS and more cranial nerve involvement. Age ≥70 years, invasive mechanical ventilation and axonal subtype, portrayed an unfavorable 3-month outcome. Further analysis demonstrated an earlier recovery in independent walk at 3 months for patients <70 years. Conclusions Elderly patients with GBS have a more severe disease at admission and encounter worse prognosis at 3-month follow-up, especially those above 70 years.
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Affiliation(s)
- Maria Eugenia Briseño-Godínez
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Antonio Arauz
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Juan Carlos López-Hernández
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Adib Jorge de Saráchaga
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Esther Y Pérez-Valdez
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Raúl Nathanael May-Más
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Gabriela López-Hernández
- Geriatrics Department, Regional General Hospital 251, Instituto Mexicano del Seguro Social (IMSS), Metepec, Mexico
| | - Lisette Bazán-Rodriguez
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Javier Andrés Galnares-Olalde
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Elizabeth León-Manríquez
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
| | - Edwin Steven Vargas-Cañas
- Neuromuscular Department, Instituto Nacional de Neurología y Neurocirugía "Manuel Velasco Suárez," Mexico City, Mexico
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López-Hernández JC, Galnares-Olalde JA, Gómez-Figueroa E, Jorge de Sarachaga A, Vargas-Cañas ES. Rituximab in Refractory Myasthenia Gravis: Experience in a Single Healthcare Center in Mexico. Cureus 2021; 13:e13226. [PMID: 33728176 PMCID: PMC7946608 DOI: 10.7759/cureus.13226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Ten to fifteen percent of patients with myasthenia gravis (MG) have treatment-refractory disease. In short series and case reports, rituximab has proven to be effective in refractory MG. Methods: A retrospective, longitudinal study was conducted. Recruitment was performed in an MG cohort from a single third-level healthcare center in Mexico. The selection included refractory MG patients that were treated with rituximab. Response after rituximab therapy was assessed with MG composite score (MGCS) and prednisone dose reduction at 6, 12, and 18 months after initiation. Wilcoxon signed-rank test was used to evaluate differences between related groups for non-continual variables. P<0.05 was considered statistically significant. Results: Ten patients (7%) fulfilled criteria for refractory MG, and eight of them were treated with rituximab. The mean age at MG diagnosis was 25.5 (±2) years, with a female predominance (75%). All our patients (100%) had positive acetylcholine receptor (AchR) antibodies. The median MG duration was six years (interquartile range [IQR] 4.2-6) before rituximab initiation. All patients were previously treated with azathioprine and 50% additionally with cyclophosphamide. The median prednisone doses before rituximab treatment and 18-month follow-up were 50 mg (IQR 30-50 mg) and 10 mg (IQR 0-20 mg), respectively (p=0.011). The median baseline MGCS and at 18-month follow-up were 19.5 (IQR 11-31) and 6 (IQR0-16), respectively (p = 0.012). Conclusion: Rituximab appears to be associated with clinical improvement and prednisone dose reduction in Latin-American patients diagnosed with anti-AchR MG. Our findings need to be interpreted in light of the limitations mentioned.
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Affiliation(s)
- Juan Carlos López-Hernández
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Javier A Galnares-Olalde
- Neurology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Enrique Gómez-Figueroa
- Neurology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Adib Jorge de Sarachaga
- Neurology, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
| | - Edwin Steven Vargas-Cañas
- Neuromuscular Diseases, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, MEX
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14
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López-Hernández JC, Colunga-Lozano LE, Galnares-Olalde JA, Vargas-Cañas ES. Electrophysiological subtypes and associated prognosis factors of Mexican adults diagnosed with guillain-barré syndrome, a single center experience. J Clin Neurosci 2021; 86:85-86. [PMID: 33775352 DOI: 10.1016/j.jocn.2020.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/10/2020] [Indexed: 11/19/2022]
Affiliation(s)
- J C López-Hernández
- Neuromuscular Diseases Clinic, National Institute of Neurology and Neurosurgery, México City, Mexico
| | - L E Colunga-Lozano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - J A Galnares-Olalde
- Neuromuscular Diseases Clinic, National Institute of Neurology and Neurosurgery, México City, Mexico
| | - E S Vargas-Cañas
- Neuromuscular Diseases Clinic, National Institute of Neurology and Neurosurgery, México City, Mexico.
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López-Hernández JC, Bazán-Rodríguez L, Pérez-Torres T, Delgado-García G, García-Trejo S, Cervantes-Uribe R, Jorge-de Saráchaga A, León-Manríquez E, Vargas-Cañas ES. [Vulpian-Bernhardt syndrome. Its frequency and clinical and electrophysiological features in a tertiary care centre in Mexico]. Rev Neurol 2021; 72:85-91. [PMID: 33506486 DOI: 10.33588/rn.7203.2020126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Vulpian-Bernhardt syndrome (VBS) is an atypical rare clinical phenotype of amyotrophic lateral sclerosis (ALS) that causes a significant delay in diagnosis, and thus it is important to recognise its clinical and electrophysiological features. MATERIALS AND METHODS Retrospective cross-sectional study. We reviewed the clinical records of patients diagnosed with ALS in the period from January to December 2019. Those meeting criteria for VBS were included so as to describe their frequency as well as their clinical and electrophysiological features. RESULTS Twenty patients (15.8%) met criteria for VBS; 55% were female; age at onset of symptoms was 46.6 ± 12.9 years; 40% were smokers; median delay in diagnosis was 24 (12-96) months; median time to involvement of the second body segment was 24 (12-132) months, which was lumbosacral in 65%; mean Revised Amyotrophic Lateral Sclerosis Functional Rating Scale score was 27 ± 7 points; 45% met the El Escorial criteria for ALS defined at diagnosis and 58.8% met the Awaji criteria. There were 19 nerve conduction studies and 17 electromyograms, and an abductor digiti minimi-abductor pollicis brevis (ADM/APB) ratio < 0.6 was found in 63% (split hand). CONCLUSIONS There is a significant delay in the diagnosis of motor neuron diseases in general and more particularly in VBS. Calculating the ADM/APB ratio and applying the Awaji criteria in the electrophysiology study can be a valuable aid to increase diagnostic certainty in this clinical entity.
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Affiliation(s)
- J C López-Hernández
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - L Bazán-Rodríguez
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - T Pérez-Torres
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - G Delgado-García
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - S García-Trejo
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - R Cervantes-Uribe
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - A Jorge-de Saráchaga
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - E León-Manríquez
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
| | - E S Vargas-Cañas
- Instituto Nacional de Neurología y Neurocirugía Dr. Manuel Velasco Suárez, Ciudad de México, México
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López-Hernández JC, Colunga-Lozano LE, Garcia-Trejo S, Gomez-Figueroa E, Delgado-Garcia G, Bazán-Rodríguez L, Cervantes-Uribe R, Burgos-Centeno J, Fernandez-Valverde F, Vargas-Cañas ES. Electrophysiological subtypes and associated prognosis factors of Mexican adults diagnosed with Guillain-Barré syndrome, a single center experience. J Clin Neurosci 2020; 80:292-297. [PMID: 32674942 DOI: 10.1016/j.jocn.2020.04.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/12/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The clinical characteristics of electrophysiological subtypes and prognostic factors of Mexican adults diagnosed with Guillain-Barré Syndrome (GBS) have not been described. MATERIALS AND METHODS A single center, ambispective, cohort study was performed (2015-2019). GBS was defined following the Asbury and Cornblath criteria. Electrodiagnosis was made according to Hadden criteria. Clinical, biochemical and electrodiagnostic parameters were described, compared and analyzed using a multivariate model. Only patients who completed a 3-month follow-up were included. RESULTS 137 GBS patients (92 males; mean age 46.6 ± 16.6).132 (96.3%) underwent an electrodiagnostic assessment.68 (51.5%) were classified as axonal GBS, with further classified into two groups: acute motor axonal neuropathy (AMAN) 45.4%, and acute motor and sensory axonal neuropathy (AMSAN) 8,6%. The following characteristics were lower in the AMAN group: Medical Research Counsel sumscore (MRC) 30.1 ± 16.3 vs 36.4 ± 14.4, unilateral facial palsy 10% vs 25.9% and albuminocytologic dissociation 41.3% vs. 71.7%.Multivariate analysis found AMAN as an independent predictor of an unfavorable outcome OR: 3.34 (p = 0.03) CONCLUSIONS: AMAN subtype is the most frequent presentation of GBS in Mexican adult patients and an independent predictor of inability to walk independently at 3 months after discharge.
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Affiliation(s)
| | | | - Sofia Garcia-Trejo
- Neuromuscular Disease Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Enrique Gomez-Figueroa
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Lisette Bazán-Rodríguez
- Department of Neurology, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Roberto Cervantes-Uribe
- Neuromuscular Disease Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Jorge Burgos-Centeno
- Department of Clincal Neuphysiology, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | | | - Edwin Steven Vargas-Cañas
- Neuromuscular Disease Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico.
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