GUILLAIN-BARRE SYNDROME

Block 9B

General Data

AB, 66M Married right-handed from Cavite Chief complaint:

generalized weakness

History of Present Illness

1 month prior to admission Patient complained of severe intermittent low

back pain characterized as shooting in character, radiating to bilateral lower extremities.

(-) numbness(-) weakness(-) incontinence Sought consult at PGH Orthopedics Assessment: Spondylolisthesis L2-L3

2 weeks prior to admission Patient complained of ascending weakness of

bilateral lower extremities, allegedly with no sensory deficits. Still ambulatory but would walk with the aid of a cane.

1 week prior to admission Can no longer ambulate, wheelchair-bound,

weakness up to the thigh level. No associated dyspnea, dysphagia or sensory deficits. There was urinary retention, which eventually resolved.

4 days PTA Weakness of bilateral upper extremities with

no associated dyspnea or pysphagia. (+) anorexia.

Sought consult in PGH

Past Medical History

Not known hypertension or DM (-) PTB, BA, CVD (+) non-healing wound, right foot (2009) (-) Food and drug allergy No previous surgery or hospitalization

Family History

(+) HTN (+) DM (-) PTB, BA, CVD, HD

Personal and Social History

Occasional smoker Heavy alcoholic beverage drinker Copra farm owner Lives with children and wife

Physical and Neurological Examination

AB, 66/M

General Awake, stretcher-bound, not in cardiorespiratory distress

Vital Signs: BP: 140/90 HR: 96 RR: 20 T: afebrile

HEENT Pink conjunctivae, anicteric sclerae, (-)ANM/CLAD/NVE

Chest/Lungs Equal chest expansion, clear breath sounds, no rales/crackles/wheezes

CVS Adynamic precordium, distinct heart sounds, (-) murmur

Abdomen Flabby, soft, normoactive bowel sounds, (-) hepatosplenomegaly, (-) masses/tenderness

GU Essentially normal

Skin/Extremities

Pink nailbeds, CRT<2 sec,full and equal pulses, (-) edema/jaundice/cyanosis

Alert, opens eyes spontaneously, speaks in sentences, follows commands

Cranial Nerve Examination

I Not assessed

II 2-3 mm EBRTL

III, IV, VI EOMs intact

V Brisk corneals

VII No facial asymmetry

VIII Weber: Lateralizes to L, AD: BC> AC AS: AC>BC

IX Good gag reflex

X Uvula midline

XI Good shoulder shrug

XII Tongue midline

No sensory deficits Motor Exam:

R L R L

Shoulder abduction 3 3 Hip flexion 0 0

Shoulder adduction 3 3 Hip extension 0 0

Elbow flexion 4 4 Knee flexion 0 0

Elbow extension 4 4 Knee extension 0 0

Wrist flexion 4 4 Ankle plantarflexion

0 0

Wrist extension 4 4 Ankle dorsiflexion

0 0

Grip good good

DTRs: areflexia all extremities (-) clonus/ Babinski Supple neck (-) nystagmus

Laboratory test resultsAB, 66/M

Lab Test Result

CBC 2/18: Hgb 82 Hct 0.236 Plt 215 WBC 21.6 N 0.962 L 0.026 M 0.009 E 0.0032/23: Hgb 83 Hct 0.254 Plt 208 WBC 11.3 N 0.880 L 0.072 M 0.046 E 0.00

Blood Chem

BUN 7.19 Crea 67 UA 0.16 Alb 13 HDL 0.25 LDL 2.6 Trig 0.81 Chole 3.22 Mg 0.74 Na 126 K 4.4 Cl 74 HbA1c 5.7

ABG pH 7.461 pCO2 25.6 PO2 86.6 HCO3 18 .2 O2sat 97 BE -3.0

PT/PTT 12.5/15.4/0.66/1.47; 36.6/40.3

Urinalysis Dark yellow, turbid, 1.015, 7.0, (-) sugar, 1+ protein, 1-4 RBC, abundant WBC, few EC, 3+ bacteria, (-) MT/cast/crystal

Urine GS PMN 5-10, Gram (+) cocci in pairs> 25/OIF

AssessmentAB, 66/M

Guillain-Barre Syndrome Complicated UTI, resloving Sacral decubitus ulcer, grade 2 Multiple electrolyte imbalance, resolving Spondylolisthesis L2-L3 Dyslipidemia Anemia, multifactorial Sensorineural hearing loss, AS

MANAGEMENTAB, 66/M

Pharmacologic

Ceftriaxone 2g IV OD Metronidazole 500/cap q6 FeSO4 + FA Simvastatin 40 mg OD Celebrex PRN Lactulose 30 cc BID

Guillain Barre Syndrome

GBS

Acute inflammatory demyelinating or axonal polyneuropathy

Common cause of acute or subacute generalized paralysis

Mild respiratory or gastrointestinal infection precedes the neuropathic symptoms

Symptomatology

Paresthesias and numbness in toes and fingers

Symmetrical weakness, lower extremities before upper extremities

Pain or aching discomfort in muscles often hip, thigh and back

Variable sensory losses Hypo- or areflexia Cranial nerve palsies come later Autonomic function disturbances

Pathophysiology

Differential Diagnosis

Acute spinal cord injury Poliomyelitis Carcinomatous meningitis Botulism Polyneuropathy of critical illness

Diagnostics

Electrodiagnostic studies EMG- reduction in the amplitude of muscle action

potentials, slowed conduction velocity, and conduction block in motor nerves singly or in combination

Prolonged distal latencies and prolonged or absent F-reflexes

CSF examination Suggestive of demyelination without evidence of

active infection Spine MRI

Lumbosacral area enhancement of nerve roots with gadolinium

Therapeutics

Aimed primarily at immunomodulation Intravenous immunoglobulin (IVIG)

Adults: 2g/kg IV over 2-5 days Children: 0.4 g/kg/d IV for 5 d; 2 g/kg once or 1

g/kg/d over 2 d Plasmapheresis may decrease the severity

and shorten the duration of GBS Removal of 200-250 ml/kg of plasma in 4-6

treatments on alternate days or on sgort period if no coagulopathy

Potential complications; autonomic instability, hypercalcemia, bleeding

Non-pharmacologic

Consultation with neurologist, rehab ,medicine specialist, and intensivist if necessary

Occupational Therapy Physical therapy

passive movement and positioning of limbs to prevent pressure palsies and, later, mild resistance exercisesoccupational therapist

Prevention of decubitus ulcers