eMedicine Specialties > Physical Medicine and Rehabilitation > Peripheral Neuropathy

Guillain-Barre Syndrome: Differential Diagnoses & Workup

Author: Heather Rachel Davids, MD, Physician, Department of Anesthesiology, Interventional Pain Medicine, University of Colorado Health Sciences Center
Coauthor(s): Joyce L Oleszek, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center, The Children's Hospital of Denver; Angela Cha-Kim, MD, Director of Spinal Cord Injury, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Contributor Information and Disclosures

Updated: Sep 15, 2009

Differential Diagnoses

Basilar Artery Thrombosis
Nutritional Neuropathy
Botulism
Poliomyelitis
Hypophosphatemia
Polymyositis
Leptomeningeal Carcinomatosis
Vasculitic Neuropathy
Lyme Disease
Metabolic Myopathies
Mononeuritis Multiplex

Other Problems to Be Considered

Toxic neuropathies (eg, arsenic, thallium, organophosphates, lead)
Multifocal motor neuropathy
Critical illness polyneuropathy
Vasculitic neuropathies
Diphtheritic polyneuritis
Acute myasthenia gravis
Tick paralysis
Paralytic shellfish poisoning
Porphyria polyneuropathy
Chronic inflammatory demyelinating polyneuropathy
Acute myelopathy (for example, from compression, transverse myelitis, vascular injury)
Periodic paralysis
Paraneoplastic neuropathy
Relapsing inflammatory polyneuropathy
Neoplastic meningitis 
Conversion disorder/hysterical paralysis

Workup

Laboratory Studies

  • CSF studies
    • During the acute phase of GBS, characteristic findings include albuminocytologic dissociation, which is an elevation in CSF protein (>0.55 g/L) without an elevation in white blood cells.
    • The increase in CSF protein is thought to reflect the widespread inflammatory disease of the nerve roots.
  • Basic laboratory studies, such as complete blood counts and metabolic panels, are of limited value in the diagnosis of GBS. They are often ordered, however, to exclude other infectious or metabolic causes of the weakness.
  • A basic peripheral neuropathy workup is recommended in cases in which the diagnosis is uncertain. These studies may include thyroid panel, rheumatology profiles, vitamin B-12, folic acid, hemoglobin A1C, erythrocyte sedimentation rate (ESR), rapid protein reagent, and immunoelectrophoresis of serum protein, as well as tests for heavy metals. The ordering of specific tests should be guided by the patient's history and presentation.
  • Serologic studies are of limited value in the diagnosis of GBS.
    • An increase in titers for infectious agents, such as CMV, EBV, or Mycoplasma, may help in establishing etiology for epidemiologic purposes.
    • HIV has been reported to precede GBS, and serology should be tested in high-risk patients to establish possible infection with this agent.
  • Serum auto-antibodies are not measured routinely in the workup of GBS, but results may be helpful in patients with a questionable diagnosis or a variant of GBS.
    • Antibodies to glycolipids are observed in the sera of 60-70% of patients with GBS during the acute phase, with gangliosides being the major target antigens.21
    • Antibodies to GM1 frequently are frequently found in the sera of patients with the motor axonal neuropathy or AIDP variants of GBS. Antecedent C jejuni infections are closely associated with elevated titers of anti-GM1 antibodies.
    • Anti-GQ1b antibodies are found in patients with GBS with ophthalmoplegia, including patients with the Miller-Fisher variant.
    • Other antibodies to different major and minor gangliosides also have been found in GBS patients.

Imaging Studies

  • Magnetic resonance imaging (MRI)
    • Although nonspecific, MRI can reveal nerve root enhancement.
    • Imaging studies, such as MRI or computed tomography (CT) scanning of the spine, may be more helpful in excluding other diagnoses, such as mechanical causes of myelopathy, than in assisting in the diagnosis of GBS.

Other Tests

  • EMG
    • EMG studies can be very helpful in the diagnostic workup of patients with suspected GBS. Abnormalities in NCS that are consistent with demyelination are sensitive and represent specific findings for classic GBS.22
    • Although NCS results classically show a picture of demyelinating neuropathy in most patients, other electrophysiologic subgroups include axonal and inexcitable groups. The inexcitable studies may represent either axonopathy or severe demyelination with distal conduction block.
    • Although most patients exhibit sensory abnormalities on NCS, these findings are much less marked than they are in motor nerves.
    • On NCS, demyelination is characterized by nerve conduction slowing, prolongation of the distal latencies, prolongation of the F-waves, conduction block, and/or temporal dispersion. Changes on NCS should be present in at least 2 nerves in regions that are not typical for those associated with compressive mononeuropathies (preferentially in anatomically distinct areas, such as an arm and a leg or a limb and the face).
    • The needle examination is of limited value in GBS. Reduced motor unit recruitment and absent denervation help to support the suggestion of a demyelinating mechanism, although the same changes can be observed in early axonal damage with pending wallerian degeneration. In severe cases, denervation changes may be observed later in the disease course.
    • In the axonal variant of the disease, absent or markedly reduced distal compound muscle action potentials (CMAP) are observed on NCS. On needle examination, profuse and early denervation potentials also support the conclusion that there has been axonal injury.
  • Pulmonary function tests
    • Maximal inspiratory pressures and vital capacities are measurements of neuromuscular respiratory function and predict diaphragmatic strength. Maximal expiratory pressures also reflect abdominal muscle strength. Frequent evaluations of these parameters should be performed at bedside to monitor respiratory status and the need for ventilatory assistance.
    • Respiratory assistance should be considered when the expiratory vital capacity decreases to <18 mL/kg or there is a decrease in oxygen saturation (arterial PO2 <70 mm Hg).

Procedures

  • Lumbar puncture for CSF studies is recommended.

Histologic Findings

Lymphocyte and macrophage infiltration is observed on microscopic examination of peripheral nerves. Macrophage influx is believed to be responsible for the multifocal demyelination seen in GBS. A variable degree of wallerian degeneration also can be observed with severe inflammatory changes. Cellular infiltrates are scattered throughout the cranial nerves, nerve roots, dorsal root ganglions, and peripheral nerves.

More on Guillain-Barre Syndrome

Overview: Guillain-Barre Syndrome
Differential Diagnoses & Workup: Guillain-Barre Syndrome
Treatment & Medication: Guillain-Barre Syndrome
Follow-up: Guillain-Barre Syndrome
References
Further Reading
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Keywords

Guillain-Barré syndrome, Guillain-Barre syndrome, Guillain-Barre, demyelination, Campylobacter jejuni, demyelinating neuropathy, polyradiculoneuropathy, GBS, C jejuni, acute inflammatory demyelinating polyradiculoneuropathy, Landry-Guillain-Barre syndrome, Landry-Guillain-Barre-Strohl syndrome, acute demyelinating neuropathy, infectious polyneuritis, acute polyradiculoneuritis, axonal Guillain-Barre syndrome, acute motor axonal neuropathy, acute motor-sensory axonal neuropathy, Miller-Fisher syndrome, pharyngeal-cervical-brachial GBS

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Contributor Information and Disclosures

Author

Heather Rachel Davids, MD, Physician, Department of Anesthesiology, Interventional Pain Medicine, University of Colorado Health Sciences Center
Heather Rachel Davids, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Coauthor(s)

Joyce L Oleszek, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver Health Sciences Center, The Children's Hospital of Denver
Joyce L Oleszek, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Angela Cha-Kim, MD, Director of Spinal Cord Injury, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Angela Cha-Kim, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and American Paraplegia Society
Disclosure: Nothing to disclose.

Medical Editor

Daniel D Scott, MD, MA, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Colorado at Denver and Health Sciences Center
Daniel D Scott, MD, MA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, National Multiple Sclerosis Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael T Andary, MD, MS, Residency Program Director, Professor, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine
Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists
Disclosure: allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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