11 Jun - Guillain-Barre syndrome

This AMs case was a 40ish year old man admitted with 4 days of progressive ascending weakness with paresthesias.  Mental status was normal.  He had a recent illness with low grade fevers and myalgias but no other significant symptoms or rashes.  He did have a tick bite about two weeks prior to onset, but did not have any attached ticks at time of admission.  Significant flaccid paralysis of the arms and legs was present and reflexes were absent.  No cranial nerve defects were evident.  He rapidly developed respiratory insufficiency requiring intubation.  CSF evaluation revealed significantly elevated protein and a clinical diagnosis of GBS was made.  He has been treated for ~8 days, initially with IVIG and subsequently plasmapheresis but is still ventilator dependent.

Differential for acute flaccid paralysis includes GBS, myasthenia gravis, botulism, tick paralysis, toxins, polio, non polio enteroviruses, and hypokalemia.  The review article linked here has a nice table that helps differentiate clinical symptoms.

A recent review of GBS is in this issue of the BMJ.

Treatment cosists of observation for mild cases, IVIG or plasmapheresis for moderate to severe.  Plasmapheresis has been shown to be effective vs placebo in clinical trials, and IVIG has been shown to be equivalent to plasmapheresis but has not been compared directly to placebo.

Pearls:

You must measure NIF and/or vital capacity - ABG and O2 sats are usually normal right up until total respiratory failure occurs

Autonomic instability (tachycardia, hypertension) is common.

Elevated CSF WBCs should make you consider an alternate diagnosis.