Neurology · Year 3 · from Neurology

Case 1: Guillain-Barre Syndrome (AIDP)

Patient Demographics

  • Age: 45 years
  • Sex: Male
  • Occupation: Construction supervisor

Chief Complaint

"My legs feel weak and tingly, and it's getting worse."

History of Present Illness

The patient developed tingling and numbness in his feet 5 days ago. Over the following days, he noticed progressive weakness in his legs, starting distally and moving proximally. He now has difficulty climbing stairs and getting up from a chair. Since yesterday, he has noticed weakness in his hands as well. He reports back pain. Two weeks ago, he had a diarrheal illness lasting 4-5 days with crampy abdominal pain (suspected Campylobacter). He denies shortness of breath or difficulty swallowing at this time, but his wife noticed his voice sounds different. No bladder or bowel dysfunction.

Neurological Examination Findings

Mental Status:

  • Alert, oriented, anxious about progressive weakness

Cranial Nerves:

  • Facial weakness bilateral (cannot fully close eyes, weak smile)
  • Mild dysarthria
  • Gag reflex: Mildly diminished
  • Extraocular movements: Intact
  • No ophthalmoplegia

Motor Examination:

  • Ascending pattern of weakness:
  • Ankle dorsiflexion: 2/5 bilateral
  • Knee flexion/extension: 3/5 bilateral
  • Hip flexion: 4/5 bilateral
  • Shoulder abduction: 4+/5 bilateral
  • Grip strength: 4/5 bilateral
  • Fine finger movements: Intact
  • Hypotonic throughout

Sensory Examination:

  • Decreased vibration sense distally (ankles)
  • Mild stocking-pattern sensory loss to pinprick
  • Preserved proprioception

Reflexes:

  • Areflexia: 0 throughout (all four extremities)
  • Plantar responses absent/mute

Coordination:

  • Limited by weakness

Gait:

  • Unable to walk without assistance
  • Foot drop bilateral

Respiratory Assessment:

  • Negative inspiratory force (NIF): -35 cm H2O (critical if < -20 to -30)
  • Forced vital capacity (FVC): 2.8 L (65% predicted) - needs monitoring

Brighton Criteria for GBS

  • Bilateral flaccid weakness (YES)
  • Decreased or absent deep tendon reflexes (YES)
  • Monophasic course with nadir 12 hours to 28 days (YES - ongoing)
  • No alternative diagnosis

Neuro Workup

  • Lumbar Puncture:
  • Opening pressure: 14 cm H2O (normal)
  • Albuminocytologic dissociation: Protein 185 mg/dL (elevated), WBC 3 (normal)
  • Glucose: Normal
  • Electrodiagnostic Studies (NCS/EMG):
  • Prolonged distal latencies (demyelination)
  • Conduction block in multiple nerves
  • Prolonged F-wave latencies
  • Reduced CMAP amplitudes
  • Findings consistent with AIDP (acute inflammatory demyelinating polyneuropathy)
  • Labs:
  • Campylobacter serology: IgM positive
  • Anti-GM1 antibodies: Positive (associated with axonal variant)
  • HIV, Lyme: Negative
  • Pulmonary Function: Serial FVC monitoring q4-6 hours

Diagnosis

Guillain-Barre Syndrome (GBS) - AIDP variant, post-infectious (Campylobacter jejuni)

Management

Acute Immunotherapy (within 2-4 weeks of onset):

  1. IVIG 0.4 g/kg/day for 5 days (2 g/kg total) - PREFERRED in this setting
  • OR Plasmapheresis: 5 exchanges over 1-2 weeks
  1. Both equally effective; IVIG more convenient
  2. Steroids NOT effective in GBS (unlike CIDP)

Respiratory Monitoring (critical):

  1. Serial FVC and NIF every 4-6 hours
  2. "20-30-40 rule" for intubation:
  • FVC <20 mL/kg
  • NIF < -30 cm H2O
  • FVC decline >30% from baseline
  1. ICU admission recommended for this patient

Supportive Care:

  1. DVT prophylaxis (SC heparin + SCDs)
  2. Pain management (gabapentin, opioids for severe pain)
  3. Autonomic monitoring (BP, HR fluctuations - can have dysautonomia)
  4. Physical therapy (prevent contractures)
  5. Nutrition support
  6. Psychological support

Complications to Monitor:

  1. Respiratory failure (25-30% need ventilator)
  2. Dysautonomia (arrhythmias, BP lability)
  3. DVT/PE
  4. Hospital-acquired infections
  5. SIADH

Prognosis:

  1. Most patients recover fully (70-80%)
  2. Recovery over weeks to months
  3. 5-10% mortality (respiratory failure, dysautonomia)
  4. 20% have persistent disability

Clinical Image

Image Description: Nerve conduction study demonstrating prolonged distal motor latency and temporal dispersion of the compound muscle action potential, consistent with demyelinating neuropathy in Guillain-Barre syndrome.

Attribution: Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Nerve_conduction_study.png

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