eMedicine Specialties > Emergency Medicine > Neurology

Guillain-Barre Syndrome: Differential Diagnoses & Workup

Author: Andrew C Miller, MD, Chief Resident and Clinical Assistant Instructor, Departments of Emergency Medicine and Internal Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Coauthor(s): Razi M Rashid, MD, MPH, Intern, Department of Internal Medicine, St John's Hospital and Medical Center, Detroit, Michigan; Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Jul 1, 2009

Differential Diagnoses

Cauda Equina Syndrome
Polymyositis
CBRNE - Botulism
Spinal Cord Infections
Diphtheria
Spinal Cord Injuries
Encephalitis
Systemic Lupus Erythematosus
Hyperkalemia
Tick-Borne Diseases, Lyme
Hypokalemia
Toxicity, Alcohols
Hypophosphatemia
Toxicity, Heavy Metals
Meningitis
Toxicity, Organophosphate and Carbamate
Multiple Sclerosis
Myasthenia Gravis

Other Problems to Be Considered

West Nile encephalitis
Basilar artery occlusion
Chronic inflammatory demyelinating polyneuropathy
Folate deficiency
Hereditary neuropathies
Neoplasia
Neurotoxic fish poisoning
Poliomyelitis
Porphyria
Sarcoid meningitis
Spinal cord compression
Spinal cord syndromes, particularly postinfection
Tick paralysis
Transverse myelitis
Vitamin B-12 deficiency
Vitamin B-6
HIV peripheral neuropathy
Thiamine deficiency

Workup

Laboratory Studies

  • Diagnosis of Guillain-Barré syndrome usually is made on clinical grounds. Laboratory studies are useful to rule out other diagnoses and to better assess functional status and prognosis.
  • Lumbar puncture and spinal fluid analysis
    • Elevated or rising protein levels on serial lumbar punctures and 10 or fewer mononuclear cells/mm3 strongly support the diagnosis.
    • Most, but not all, patients have an elevated CSF protein level (>400 mg/L), with normal CSF cell counts.
    • Normal CSF protein level does not rule out Guillain-Barré syndrome as the level may remain normal in 10% of patients, and a rise in the CSF protein level may not be observed until 1-2 weeks after the onset of weakness.
    • CSF pleocytosis is well recognized in HIV-associated Guillain-Barré syndrome.
  • Biochemical screening
    • Biochemical screening includes electrolyte levels; liver function tests (LFTs); CPK level; erythrocyte sedimentation rate (ESR); antiganglioside antibodies; and antibodies to C jejuni, cytomegalovirus, Ebstein-Barr virus, herpes simplex virus (HSV), HIV, and M pneumoniae.
    • Syndrome of inappropriate antidiuretic hormone (SIADH) occurs in some patients with Guillain-Barré syndrome.
    • LFT results are elevated in up to one third of patients.
    • CPK and ESR may be elevated with myopathies or systemic inflammatory conditions.
    • Patients with the Miller-Fisher variant may have anti-GQ1b antibodies.
    • Patients who have antibody subtype GM1 may have worse prognoses.
  • Stool culture for C jejuni
  • Pregnancy test

Imaging Studies

  • MRI
    • MRI is a sensitive but nonspecific test.
    • Spinal nerve root enhancement with gadolinium is a nonspecific feature seen in inflammatory conditions and is caused by disruption of the blood-nerve barrier.
    • Selective anterior nerve root enhancement appears to be strongly suggestive of GBS.
    • The cauda equine nerve roots are enhanced in 83% of patients.

Other Tests

  • Forced vital capacity29
    • Forced vital capacity (FVC) is very helpful in guiding disposition and therapy.
    • Patients with an FVC less than 15-20 mL/kg, maximum inspiratory pressure less than 30 cm H2 O, or a maximum expiratory pressure less than 40 cm H2 O generally progress to require prophylactic intubation and mechanical ventilation.
  • Nerve conduction studies2
    • A delay in F waves is present, implying nerve root demyelination.
    • Nerve motor action potentials may be decreased. This is technically difficult to determine until the abnormality is severe.
    • Compound muscle action potential (CMAP) amplitude may be decreased.
    • Frequently, patients show evidence of conduction block or dispersion of responses at sites of natural nerve compression. The extent of decreased action potentials correlates with prognosis.
    • Prolonged distal latencies may be present.
    • Rarely neurophysiologic testing is normal in patients with Guillain-Barré syndrome. This is believed to be due to the location of demyelinating lesions in proximal sites not amenable to study.
  • Muscle biopsy may help to distinguish Guillain-Barré syndrome from a primary myopathy in unclear cases.
  • Many different abnormalities may be seen on ECG, including second-degree and third-degree atrioventricular (AV) block, T-wave abnormalities, ST depression, QRS widening, and a variety of rhythm disturbances.

Procedures

  • Lumbar puncture and spinal fluid analysis

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
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Further Reading

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Keywords

Guillain-Barre syndrome, Guillain-Barré syndrome, GBS, nervous system, myelin sheath, neuropathy, nerves, causes, symptoms, treatment, viral infection, weakness, autoimmune disease, acute inflammatory demyelinating polyneuropathy, AIDP, acute motor axonal neuropathy, AMAN, acute motor-sensory axonal neuropathy, AMSAN, Miller-Fisher syndrome, MFS, acute panautonomic neuropathy, pharyngeal-brachial-cervical variant, pure sensory variant, Campylobacter jejuni, IVIG, plasmapheresis, acute flaccid paralysis

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Contributor Information and Disclosures

Author

Andrew C Miller, MD, Chief Resident and Clinical Assistant Instructor, Departments of Emergency Medicine and Internal Medicine, State University of New York Downstate Medical Center, Kings County Hospital Center
Andrew C Miller, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Association, Emergency Medicine Residents Association, Islamic Medical Association of North America, Medical Society of the State of New York, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Razi M Rashid, MD, MPH, Intern, Department of Internal Medicine, St John's Hospital and Medical Center, Detroit, Michigan
Disclosure: Nothing to disclose.

Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Edward A Michelson, MD, Program Director, Associate Professor, Department of Emergency Medicine, University Hospital Health Systems in Cleveland
Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

J Stephen Huff, MD, Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center
J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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