eMedicine Specialties > Emergency Medicine > Neurology

Guillain-Barre Syndrome

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
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

Updated: Jul 1, 2009

Introduction

Background

In 1859, Landry published a report on 10 patients with an ascending paralysis.¹ This was followed by a report in 1916 written by 3 French physicians working in the Sixth Army camp during the First World War; they described 2 French soldiers with motor weakness, areflexia, and albuminocytological dissociation in the cerebrospinal fluid.² In this report Guillain, Barr é, and Strohl carefully recorded and interpreted the tendon reflexes of their patients and recognized the peripheral nature of the illness. The identified syndrome was later named Guillain-Barr é syndrome (GBS). Historically, GBS was a single disorder; however, current practice acknowledges several variant forms.

GBS is a heterogeneous grouping of immune-mediated processes generally characterized by motor, sensory, and autonomic dysfunction. In its classic form, GBS is an acute inflammatory demyelinating polyneuropathy characterized by progressive symmetric ascending muscle weakness, paralysis, and hyporeflexia with or without sensory or autonomic symptoms; however, variants involving the cranial nerves or pure motor involvement are not uncommon. In severe cases, muscle weakness may lead to respiratory failure, and labile autonomic dysfunction may complicate the use of vasoactive and sedative drugs.

Pathophysiology

Although the clinical syndrome of Guillain-Barré syndrome classically presents as a rapidly progressive acute polyneuropathy, several pathologic and etiologic subtypes exist. Most patients with Guillain-Barré syndrome exhibit absent or profoundly delayed conduction in action nerve fibers. This aberrant conduction results from axon demyelination occurring primarily in peripheral nerves and spinal roots, but cranial nerves may be involved as well.

Guillain-Barré syndrome is believed to result from autoimmune humoral- and cell-mediated responses to a recent infection or any of a long list of medical problems. Its relation to antecedent infections and the identification of various antiganglioside antibodies suggest that molecular mimicry may serve as a possible mechanism.^3,4  Antibodies formed against ganglioside-like epitopes in the lipopolysaccharide (LPS) layer of some infectious agents have been shown in both necropsy and animal models to cross-react with the ganglioside surface molecules of peripheral nerves.³ Symptoms generally coincide pathologically with various patterns of lymphocytic infiltration and macrophage-mediated demyelination, depending on the subtype in question. Recovery is typically associated with remyelination. In a subset of patients, GBS is associated primarily with myelin-sparing axonal damage resulting from a direct cellular immune attack on the axon itself.

The acute inflammatory demyelinating polyneuropathy (AIDP) subtype is the most commonly identified form in the United States. It is generally preceded by a bacterial or viral infection. Nearly 40% of patients are seropositive for Campylobacter jejuni. Lymphocytic infiltration and macrophage-mediated demyelination of peripheral nerves is present. Symptoms generally resolve with remyelination.

The acute motor axonal neuropathy (AMAN) subtype is a purely motor subtype that is more prevalent amongst pediatric age groups. Nearly 70-75% of patients are seropositive for Campylobacter. One third of these cases may actually be hyperreflexic. The hyperreflexia mechanism associated with AMAN is not known, but dysfunction of the inhibitory system via spinal interneurons may increase motor neuron excitability. Hyperreflexia is significantly associated with the presence of anti-GM1 antibodies.¹ Inflammation of the spinal anterior roots may lead to disruption of the blood-CNS barrier.³ AMAN is generally characterized by a rapidly progressive weakness, ensuing respiratory failure, and good recovery.

Acute motor-sensory axonal neuropathy (AMSAN) is an acute severe illness differing from AMAN in that AMSAN also affects sensory nerves and roots.⁵  Patients are typically adults with both motor and sensory dysfunction, marked muscle wasting, and poor recovery.

Miller-Fisher syndrome (MFS) is a rare variant that typically presents with the classic triad of ataxia, areflexia, and ophthalmoplegia. Acute onset of external ophthalmoplegia is a cardinal MFS feature.³ The ataxia tends to be out of proportion to the degree of sensory loss. Patients may also have mild limb weakness, ptosis, facial palsy, or bulbar palsy. Anti-GQ1b antibodies are prominent in this variant, and patients have reduced or absent sensory nerve action potentials and absent tibial H reflex.⁶  Patients with acute oropharyngeal palsy carry anti-GQ1b/GT1a IgG antibodies.³ Recovery generally occurs within 1-3 months.

Acute panautonomic neuropathy is the rarest of all variants and involves both the sympathetic and parasympathetic nervous systems. Cardiovascular involvement is common, and dysrhythmias are a significant source of mortality in this form of the disease. The patient may also experience sensory symptoms. Recovery is gradual and often incomplete.

Frequency

United States

The incidence of Guillain-Barré syndrome (GBS) is 1-3 per 100,000 inhabitants, making GBS the most common cause of acute flaccid paralysis in the United States.^1,2,7

International

AMAN and AMSAN occur mainly in northern China, Japan, and Mexico, and they comprise 5-10% percent of GBS cases in the United States.⁸

AIDP accounts for up to 90% of cases in Europe, North America, and the developed world.

Epidemiologic studies from Japan indicate that, in this region, a greater percentage of GBS cases are associated with antecedent C jejuni infections and a lesser number are related to antecedent cytomegalovirus infections compared with that in North America and Europe.

A study in Iran showed that 47% of pediatric GBS cases had evidence of recent C jejuni infection.⁹

Mortality/Morbidity

Most patients (up to 85%) with GBS achieve a full and functional recovery within 6-12 months. Recovery is maximal by 18 months past onset.¹⁰

• Patients may have persistent weakness, areflexia, imbalance, or sensory loss. Approximately 7-15% of patients have permanent neurologic sequelae including bilateral footdrop, intrinsic hand muscle wasting, sensory ataxia, and dysesthesia.
• The mortality rate varies but may be less than 5% in tertiary care centers with a team of medical professionals who are familiar with GBS management. Causes of death include adult respiratory distress syndrome, sepsis, pneumonia, pulmonary emboli, and cardiac arrest.
• Despite intensive care, 3-8% of patients die.
• GBS can rarely be a recurrent disorder.¹¹     

Race

No racial preponderance exists.

Sex

The male-to-female ratio of Guillain-Barré syndrome is 1.5:1. A Swedish epidemiologic study indicated that the incidence of Guillain-Barré syndrome is lower during pregnancy and increases in the months immediately following delivery.¹²

Age

Guillain-Barré syndrome occurs at all ages, but a bimodal distribution with peaks in young adulthood (15-35 y) and in elderly persons (50-75 y) appears to exist. Rare cases have been noted in infants.¹³

Clinical

History

The typical patient with Guillain-Barré syndrome (GBS) (likely AIDP) presents 2-4 weeks after a relatively benign respiratory or gastrointestinal illness complaining of dysesthesias of the fingers and lower extremity proximal muscle weakness. The weakness may progress over hours to days to involve the arms, truncal muscles, cranial nerves, and muscles of respiration. The illness progresses from days to weeks, with the mean time to the nadir of clinical function being 12 days and 98% of patients reaching a nadir by 4 weeks. A plateau phase of persistent, unchanging symptoms then ensues followed days later by gradual symptom improvement. The mean time to improvement and clinical recovery are 28 and 200 days, respectively.

• Up to one third of patients require mechanical ventilation during the course of their illness. Causes for this include cranial nerve involvement affecting airway maintenance and respiratory muscle paralysis.
• Motor dysfunction
  • Symmetric limb weakness typically begins as proximal lower extremity weakness and ascends to involve the upper extremities, truncal muscles, and head.
  • Inability to stand or walk despite reasonable strength, especially when ophthalmoparesis or impaired proprioception is present.
  • Respiratory muscle weakness with shortness of breath may be present.
  • Cranial nerve palsies (III-VII, IX-XII) may be present. Patients may present with facial weakness mimicking Bell palsy, dysphagia, dysarthria, ophthalmoplegia, and pupillary disturbances. The Miller-Fisher variant is unique in that this subtype begins with cranial nerve deficits.
  • Lack of deep tendon reflexes is a hallmark sign.
• Sensory dysfunction
  • Paresthesia generally begins in the toes and fingertips and progresses upward but generally not extending beyond the wrists or ankles.
  • Pain is most severe in the shoulder girdle, back, buttocks, and thighs and may occur with even the slightest movements.
  • Loss of vibration, proprioception, touch, and pain distally may be present.
• Autonomic dysfunction
  • Cardiovascular signs may include tachycardia, bradycardia, dysrhythmias, wide fluctuations in blood pressure, and postural hypotension.
  • Urinary retention due to urinary sphincter disturbances may be noted.
  • Constipation due to bowel paresis and gastric dysmotility may be present.
  • Facial flushing and venous pooling secondary to abnormal vasomotor tone may be present.
  • Hypersalivation
  • Anhydrosis
  • Tonic pupils
• Papilledema secondary to elevated intracranial pressure is present in rare cases.
• Miller-Fisher variant presents with a predominance of cranial nerve findings, ataxia, and areflexia. Facial weakness, ophthalmoplegias, dysarthria, and dysphagia may precede ataxia, areflexia, and weakness.¹⁴  

Physical

• Vital signs
  • Patients may have tachycardia or bradycardia, hypertension or hypotension, or hyperthermia or hypothermia.
  • Low oxygen saturation may be present with advanced respiratory muscle involvement.
• Cranial nerves: Patients may present with facial weakness mimicking Bell palsy, dysphagia, dysarthria, ophthalmoplegia, and pupillary disturbances.
• Dysreflexia
  • Patients with manifest weakness are invariably hyporeflexic or areflexic in the involved areas.
  • Respiratory symptoms
  • Poor inspiratory effort or diminished breath sounds
• Motor
  • Symmetric limb weakness typically begins as proximal lower extremity weakness and ascends to involve the upper extremities, truncal muscles, and head.
  • Inability to stand or walk despite reasonable strength, especially when ophthalmoparesis or impaired proprioception is present.
  • Hypotonia
  • Wasting of limb muscles is not an acute finding.
• Abdominal
  • Paucity or absence of bowel sounds suggests paralytic ileus.
  • Suprapubic tenderness or fullness may be suggestive of urinary retention.
• Sensory: Patients may experience numbness, paresthesias, impaired proprioception, and pain.
• Papilledema secondary to elevated intracranial pressure is present in rare cases.

Causes

Guillain-Barré syndrome (GBS) has been associated with antecedent bacterial and viral infections, administration of certain vaccinations, and other systemic illnesses. Case reports exist regarding numerous medications and procedures; however, whether any causal link exists is unclear.

• Bacterial infections include C jejuni, Haemophilus influenzae, Mycoplasma pneumoniae, and Borrelia burgdorferi.^1,7
• Viral infections include cytomegalovirus, Ebstein-Barr virus, and during seroconversion with the human immunodeficiency virus (HIV).^1,7
• Vaccines
• A study reviewing the cases of Guillain-Barré syndrome (GBS) during the 1992-1993 and 1993-1994 influenza seasons found an adjusted relative risk of 1.7 cases per 1 million influenza vaccinations.¹⁵
• Epidemiologic studies from Finland and southern California failed to validate an earlier retrospective study from Finland suggesting a cause-effect relationship between oral polio vaccination and GBS,^16,17  while a Brazilian study suggested that, based on a temporal association between the vaccine and the onset of GBS, the vaccine may rarely trigger GBS.¹⁸
• Data from a large-scale epidemiologic study found that fewer cases of GBS occurred following administration of tetanus toxoid containing vaccinations than occurred in the baseline population.¹⁹
• An epidemiologic study failed to show any conclusive epidemiologic association between GBS and the hepatitis B vaccine.²⁰
• A large Latin American study of more than 2000 children with GBS following a mass measles vaccination program in 1992 and 1993 failed to establish a statistically significant causal relationship between administration of the measles vaccine and GBS.²¹
• A recent report from the Centers for Disease Control and Prevention (CDC) suggests that an increased incidence of GBS may exist amongst recipients of the Menactra meningococcal conjugate vaccine.²²
• A recent study found no evidence of an increased risk of Guillain-Barré syndrome after seasonal influenza vaccine.²³
• Case reports exist regarding group A streptococci vaccines, the rabies vaccine, and the swine flu vaccine; however, conclusive statistically significant evidence is lacking.
• Medications²⁴
• A case-controlled study showed that patients with Guillain-Barré syndrome had used antimotility drugs and penicillins more often and oral contraceptives less often. No definite cause-effect relationship has been established.
• Case reports of Guillain-Barré syndrome associated with tumor necrosis factor antagonist agents used in rheumatoid arthitis.^25,26,27
• Case reports exist regarding streptokinase, isotretinoin, danazol, captopril, gold, heroin, and epidural anesthesia among others.
• Case reports cite associations between bariatric and other gastric surgeries.²⁸
• Anecdotal associations include systemic lupus erythematosus, sarcoidosis, lymphoma, surgery, renal transplantation, and snake bite.

Differential Diagnoses

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

Treatment

Prehospital Care

• ABCs, IV, oxygen, and assisted ventilation may be indicated.
• Monitor for cardiac arrhythmias.
• Transport expeditiously.

Emergency Department Care

• ABCs, IV, oxygen, and assisted ventilation may be indicated.
• Intubation should be performed on patients who develop any degree of respiratory failure. Clinical indicators of the need for intubation include hypoxia, rapidly declining respiratory function, poor or weak cough, and suspected aspiration. Typically, intubation is indicated when the FVC is less than 15 mL/kg.³⁰
• Patients who have, or are suspected of having, Guillain-Barré syndrome (GBS) should be monitored closely for changes in blood pressure, heart rate, and other arrhythmias.
  • Treatment rarely is needed for tachycardia.
  • Atropine is recommended for symptomatic bradycardia.
  • Because of the lability of dysautonomia, hypertension is best treated with short-acting agents, such as a short-acting beta-blocker or nitroprusside.
  • Hypotension of dysautonomia usually responds to intravenous fluids and supine positioning.
  • Temporary pacing may be required for patients with second-degree and third-degree heart block.

Consultations

• Consult a neurologist if any uncertainty exists as to the diagnosis.
• Consult the ICU team for evaluation of need for admission to the unit.

Medication

Only plasma exchange (PE) therapy and intravenous immune serum globulin (IVIG) have proven effective for Guillain-Barré syndrome (GBS). Both therapies have been shown to shorten recovery time by as much as 50%. IVIG is easier to administer and has fewer complications than plasma exchange.³¹  The cost and efficacy of the 2 treatments are comparable.

Randomized trials in severe disease show that IVIG started within 4 weeks from onset hastens recovery as much as plasma exchange.^32,33,34,35  Combining plasma exchange and IVIG neither improved outcomes nor shortened the duration of illness.³⁶  IVIG has also been proven safe and effective in the treatment of pediatric GBS.^36,37  Additionally, IVIG is the preferential treatment in hemodynamically unstable patients and in those unable to ambulate independently.^38,36  

Corticosteroids are ineffective as monotherapy.^2,5 Limited evidence shows that oral corticosteroids significantly slow recovery from GBS.³³ Substantial evidence shows that intravenous methylprednisolone alone does not produce significant benefit or harm. In combination with IVIG, intravenous methylprednisolone may hasten recovery but does not significantly affect the long-term outcome.^33,39

Immunoadsorption is an alternative that is still in the early stages of investigation. A small prospective study showed no difference in outcome between patients treated with immunoadsorption and those treated with plasma exchange.⁴⁰

Interferon beta was not associated with significant clinical improvement compared with controls in a small randomized control trial.⁴¹

Simple analgesics or nonsteroidal anti-inflammatory drugs may be tried but often do not provide adequate pain relief. Single, small randomized controlled trials support the use of gabapentin or carbamazepine in the intensive care unit for the treatment of pain in the acute phase of GBS. Adjuvant therapy with tricyclic antidepressant medication, tramadol, gabapentin, carbamazepine, or mexiletine may aid in the long-term management of neuropathic pain.⁴²

Time to development of deep vein thrombosis (DVT) or pulmonary embolism varies from 4-67 days following symptom onset.⁴² DVT prophylaxis with gradient compression hose and subcutaneous low molecular weight heparin (LMWH) may cause a dramatic reduction in the incidence of venous thromboembolism, one of the major sequela of extremity paralysis.⁴²

True gradient compression stockings (30-40 mm Hg or higher) are highly elastic, providing a gradient of compression that is highest at the toes and gradually decreases to the level of the thigh. This reduces capacity venous volume by approximately 70% and increases the measured velocity of blood flow in the deep veins by a factor of 5 or more.

The ubiquitous white stockings known as antiembolic stockings or thromboembolic disease (TED) hose produce a maximum compression of 18 mm Hg and rarely are fitted in such a way as to provide adequate gradient compression. They have not been shown to be effective as prophylaxis against thromboembolism.

Blood product derivatives

These agents are used to improve the clinical and immunologic aspects of the disease. They may decrease autoantibody production and increase solubilization and removal of immune complexes.

Intravenous immune globulin (IVIG, Gammagard S/D)

May neutralize circulating myelin antibodies through anti-idiotypic antibodies and down-regulate proinflammatory cytokines, including interferon-gamma (INF-gamma). In addition, may block the complement cascade and promote remyelination.

Dosing

Adult

0.4 g/kg/d IV for 5 d

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; IgA deficiency and anti-IgE/IgG antibodies

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Check serum IgA level before IVIG (use an IgA-depleted product, eg, Gammagard S/D); infusions may increase serum viscosity and thromboembolic events; infusions may increase risk of migraine attacks, aseptic meningitis (10%), urticaria, pruritus, or petechiae (2-30 d postinfusion)
Increases risk of renal tubular necrosis in elderly patients and in patients with diabetes, volume depletion, and preexisting kidney disease; laboratory result changes associated with infusions include elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk, and apparent hyponatremia

Albumin (Albuminar, Albumisol, Albunex, Albutein)

Used in plasma exchange when the patient's plasma is exchanged with a plasma substitute. May remove autoantibodies and immune complexes from serum. Plasma exchange is carried out with albumin (50 mL/kg) over a 10-d period. Has been shown to decrease recovery time by 50%. May aid in removing cytotoxic constituents from serum.

Dosing

Adult

Remove 3-4 L of the patient's plasma and substitute with albumin; administered IV

Pediatric

<16 years: Not established
>16 years: Administer as in adults

Interactions

None reported

Contraindications

Pulmonary edema; renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

While theoretically attractive, no proven benefit of colloid resuscitation over isotonic crystalloids exists

Fractionated low molecular weight heparins

These agents are used in the prophylaxis of DVT. Fractionated LMWH first became available in the United States as enoxaparin (Lovenox). LMWH has been used widely in pregnancy, although clinical trials are not yet available to demonstrate that it is as safe as unfractionated heparin.

Reversible elevation of hepatic transaminase levels occurs occasionally. Heparin-associated thrombocytopenia has been observed with fractionated low molecular weight heparin.

Enoxaparin (Lovenox)

Enhances the inhibition of factor Xa and thrombin by increasing antithrombin III activity. Also slightly affects thrombin and clotting time and preferentially increases the inhibition of factor Xa. Has a wide therapeutic window; prophylactic dose is not adjusted based on the patient's weight. Enoxaparin is safer and more effective than unfractionated heparin for prophylaxis of venous thromboembolism. Average duration of treatment is 7-14 d.

Dosing

Adult

30 mg SC bid

Pediatric

Not established
The following doses have been suggested:
<2 months: 0.75 mg/kg/dose bid SC
>2 months to 18 years: 0.5 mg/kg/dose bid SC

Interactions

Platelet inhibitors or oral anticoagulants such as dipyridamole, salicylates, aspirin, NSAIDs, sulfinpyrazone, and ticlopidine may increase risk of bleeding

Contraindications

Documented hypersensitivity; major bleeding and thrombocytopenia

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

If thromboembolic event occurs despite LMWH prophylaxis, discontinue drug and initiate alternate therapy; elevation of hepatic transaminase levels may occur but is reversible; heparin-associated thrombocytopenia may occur with fractionated LMWH; 1 mg of protamine sulfate will reverse effect of approximately 1 mg of enoxaparin if significant bleeding complications develop

Follow-up

Further Inpatient Care

• Admission to the ICU should be considered for all patients with labile dysautonomia, an FVC of less than 20 mL/kg, or severe bulbar palsy.⁴²
• Any patients exhibiting clinical signs of respiratory compromise, in any degree, also should be admitted to an ICU.⁴²
• The risk of sepsis and infection can be decreased by use of minimal sedation, frequent physiotherapy, and mechanical ventilation with positive end expiratory pressure where appropriate.⁴²
• The risk of DVT and pulmonary embolus may be minimized by administration of heparin or a low molecular weight heparin and intermittent pneumatic compression devices.⁴²
• The use of cardiac telemetry and pacing in the case of severe bradycardia may help to reduce the risk of cardiac morbidity and mortality.⁴²
• Pain may be symptomatically improved by frequent passive limb movements, gentle massage, frequent position changes, and use of carbamazepine and gabapentin.^43,42
• Narcotics should be used judiciously because patients may already be at risk for ileus.⁴²

Further Outpatient Care

• Physical therapy and occupational therapy may be beneficial in helping patients with Guillain-Barré syndrome to regain their baseline functional status.^10,42

Transfer

• Transfer may be appropriate if a facility does not have the proper resources to care for patients who may require prolonged intubation or prolonged intensive care.

Complications

• With modern methods of respiratory management, most complications result from long-term paralysis. Possible complications include the following:
  • Persistent paralysis
  • Respiratory failure, mechanical ventilation
  • Hypotension or hypertension
  • Thromboembolism, pneumonia, skin breakdown
  • Cardiac arrhythmia
  • Ileus
  • Aspiration
  • Urinary retention
  • Psychiatric problems such as depression and anxiety
  • Nephropathy reported in pediatric patients⁴⁴

Prognosis

• Poor prognosis for patients with Guillain-Barré syndrome is associated with rapid progression of symptoms, advanced age, prolonged ventilation (>1 mo), and severe reduction of action potentials on neuromuscular testing.
• Published reports indicate full recovery may be expected in 50-95% of patients with Guillain-Barré syndrome.
• Long-term follow-up studies show nearly 50% of patients exhibit histological and clinical residual neuropathies years after the initial syndrome. Patients may have residual motor and sensory dysfunction.⁴⁵
• Increased CSF levels of neurone-specific enolase and S-100b protein are associated with longer duration of illness.¹  
• A longer-lasting increase in IgM anti-GM1 predicts slow recovery.¹
• Neurologic sequelae
  • Reported incidence of permanent neurologic sequelae ranges from 10-40%.
  • The worst-case scenario is tetraplegia within 24 hours with incomplete recovery after 18 months or longer.
  • The best-case scenario is mild difficulty walking, with recovery within weeks.
  • The usual scenario is peak weakness in 10-14 days with recovery in weeks to months. Average time on a ventilator (without treatment) is 50 days.
  • Recent studies report that patients with Guillain-Barré syndrome may exhibit long-term differences in pain intensity, fatigability, and functional impairment compared with healthy controls.⁴⁶
• Mortality
  • Most cases of mortality are due to severe autonomic instability or from the complications of prolonged intubation and paralysis.^47,48,49,29
  • Mortality rates range from 5-10%.

Patient Education

• For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education article Guillain-Barré Syndrome.

Miscellaneous

Medicolegal Pitfalls

• Failure to anticipate dysrhythmias and autonomic instability
• Failure to anticipate progressive respiratory failure
• Failure to correctly diagnose Guillain-Barré syndrome in patients with a variant form of the disease or in those with a normal CSF protein
• Failure to provide adequate DVT prophylaxis in a patient that develops a DVT and/or pulmonary embolism

Special Concerns

• The leading cause of death in elderly patients with Guillain-Barré syndrome is arrhythmia.
• Recurrence of Guillain-Barré syndrome is rare but has been reported in 2-5% of patients.⁵⁰
• Variants of Guillain-Barré syndrome may present with pure motor dysfunction or acute dysautonomia.
• The Miller-Fisher syndrome is a variant of Guillain-Barré syndrome in which the initial symptoms include ataxia, ophthalmoplegia, and areflexia.

References

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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

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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