Gitelman Syndrome Manifesting With Acute Hypokalemic Paralysis: A Case Report

Gitelman syndrome (GS) is a rare renal tubulopathy, classically characterized by renal salt wasting and metabolic alkalosis. It is usually an incidental diagnosis, being asymptomatic or with mild symptoms. GS manifesting with acute flaccid paralysis is extremely uncommon. We report a case of GS that mimicked Guillain-Barré syndrome (GBS), manifesting with acute hypokalemic paralysis. A middle-aged male with no known comorbidities presented to our center with paresthesias of all four limbs for one month and progressive, asymmetric limb weakness over the past eight days. Neurological examination revealed hypotonia, global areflexia, and power ranging from 3/5 to 4/5 in all four limbs, leading to our initial clinical diagnosis of GBS. Our patient's laboratory panel revealed hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalcemia, characteristic of GS. Additionally, he had significantly elevated creatine phosphokinase, suggestive of rhabdomyolysis. Further urine studies revealed renal potassium wasting, confirming the diagnosis of GS. Whole exome genome sequencing for common causative genes and workup for autoimmune disease were both negative. With gradual electrolyte correction, the patient rapidly improved symptomatically. Our case highlights an uncommon initial presentation of GS and emphasizes the need for more literature on its manifestations from the Indian subcontinent.

Neuroborreliosis Presenting as Guillain-Barré Syndrome

Lyme disease (LD) is the most common vector-borne disease in the United States. The early localized disease presents with erythema migrans and nonspecific constitutional symptoms. A neurological manifestation of LD (neuroborreliosis) is only seen in 10-15% of LD cases, and it typically presents as cranial neuritis or painful radiculitis. We report a case of a 33-year-old male who presented with progressive ascending bilateral lower extremities weakness with paresthesia in hands and feet following an upper respiratory tract infection and an abdominal rash. Cerebrospinal fluid (CSF) analysis revealed albuminocytologic dissociation. An electrodiagnostic study showed prolonged distal motor latency, conduction block, and absent F-wave response. Magnetic resonance imaging of the lumbar spine revealed enhancement of the cauda equina nerve roots. After a lack of improvement with intravenous immunoglobulin for presumed Guillain-Barré syndrome (GBS), Lyme serologies were sent and showed positive Lyme antibodies in serum and CSF as well as positive western blot IgM followed by IgG seroconversion a week later. The patient was started on IV ceftriaxone and doxycycline for four weeks with significant improvement in his symptoms. This is a rare case of LD presenting as GBS. Lyme can have diverse neurologic manifestations and should be considered in the differential diagnosis of GBS in the appropriate settings.

Guillain-Barre Syndrome, Neuroborreliosis, or Both

Guillain-Barre syndrome (GBS) is an acute paralytic neuropathy. Limited reports of GBS caused by tick-borne pathogens exist. Lyme disease is a tick-borne infectious disease that is commonly caused by Borrelia burgdorferi. The nervous system may be involved and is called neuroborreliosis.

In this case, we report a 30-year-old female who presented to the emergency department with one week of diffuse, increasing weakness in the upper/lower extremities and face after a recent gastrointestinal illness and travel to the Northeastern United States. Areflexia was noted in bilateral lower extremities. Lumbar puncture results together with clinical presentation were consistent with a diagnosis of GBS. Lab results later revealed a possible Lyme infection in cerebrospinal fluid, which along with recent travel to endemic area gave high suspicion for Lyme disease. The patient was treated for both diseases with significant improvement.

Taking a good history is an essential first step in diagnosis, as travel history was key in testing for Lyme.

Beyond the Liver, Hepatitis E Can Affect the Nerves, Pancreas, and Blood Vessels. Extrahepatic Manifestations of Hepatitis E: A Comprehensive Literature Review

Extrahepatic manifestations of Hepatitis E, though rare, are being increasingly reported in the medical literature. In this review article, we will discuss the extrahepatic manifestations of hepatitis E, such as Guillain-Barre syndrome, pancreatitis, and cryoglobulinemia, their clinical association with hepatitis E, and their management.

Post Vaccination Guillain Barre Syndrome: A Case Report

Guillain-Barre syndrome is a rare but fatal autoimmune disease. The exact cause of Guillain-Barre syndrome is still unknown. The most common known etiology of Guillain-Barre syndrome is infectious disease notably caused by Campylobacter jejuni. A very small fraction of people can develop Guillain-Barre syndrome due to vaccines and vaccinations like a meningococcal vaccine, poliovirus vaccine, influenza vaccine, and rabies vaccine. Of all these, rabies is fatal invariably. It can be preventable if diagnosed early and post-exposure treatment is followed according to the World Health Organization guidelines. Older formulations of rabies vaccines are cultured in the neural tissues and have been found to have an increased risk of Guillain-Barre syndrome. Although less immunogenic older formulations of rabies vaccines are more commonly used in Asian and South American countries due to their cost-effective nature. There is little to no data available on the incidence of Guillain-Barre syndrome due to vaccinations in Pakistan. Most of the cases of Guillain-Barre syndrome due to vaccination are either undiagnosed or misdiagnosed. In this case report, we are presenting a case of vaccine-associated Guillain-Barre syndrome due to neural tissue anti-rabies vaccine in a young girl, who presented with lower limb weakness, inability to pass urine and abdominal pain.

Guillain-Barré Syndrome After Revision Lumbar Surgery: A Case Report

Guillain-Barré syndrome (GBS) is a term that is used to describe a group of immune-mediated peripheral neuropathies, with the most common feature being rapid polyradiculoneuropathy. The exact etiology of this syndrome is unknown. In the field of orthopedics, GBS has been reported to occur after total hip arthroplasty, orthopedic trauma, and spine surgery. We report a unique case of GBS after elective revision lumbar spine surgery. A 62-year-old female presented with persistent low back pain and radiculopathy and elected to have revision lumbar spine surgery. Approximately 24 to 36 hours after hospital discharge, she returned to the hospital with weakness in her legs. After an electromyography (EMG), the patient was diagnosed with GBS and placed on intravenous immunoglobulin (IVIG). She developed respiratory failure, which required intubation and eventually converted to a tracheostomy and was finally decannulated. Over the course of 12 months, she improved to her pre-surgical baseline, gaining 5/5 strength in her upper and lower extremities and was able to ambulate independently without any aids. This was a case of GBS that occurred in a patient approximately two weeks after revision lumbar surgery. GBS is a poorly understood and rare complication of lumbar spine surgery that needs to be recognized quickly to be effectively treated.