Guillain-Barré

Syndrome
GROUP 4
SORIANO, LEONARDO | SUNGALON-CALIWAG, KWIN ANNE |
SYGUIA, NICKY | YCONG, HANNAH ELISE | TACORDA, RENEE
 Objectives

e of a 24 year old female complaining of weakness

remities

salient features of the case

imary impression and differential diagnoses
laboratory findings and course in the ward of the

disease and its pathophysiology

he final diagnosis and management of the case
General data

● 24 year old
● Female
● Single
● Filipino
● Catholic
● Living in Malabon City
● Admitted for the first time at Fatima University Medical Center
Weakness of
lower
extremities
CHIEF COMPLAINT
 HISTORY OF
PRESENT ILLNESS
4 DAYS PTA weakness of the lower extremities, “heaviness”
difficulty in ambulation
non-productive cough
numbness of both upper extremities, palm of both hands
associated with nasal
baggy eyelids and shallow right nasolabial fold
congestion,
denied any headache, seizures, behavior change,
undocumented fever,
cognitive decline, and chest pain, difficulty of breathing,
body malaise 6 DAYS bowel / bladder changes, or eye pain
PTA Bell’s palsy

2 WEEKS Methylprednisolone FHPTA

PTA blurring of vision Vitamin B complex worsening of symptoms especially
Sought consult with an Tears naturale on lower extremity weakness
ophthalmic drops. described as “heaviness” from her
ophthalmologist thighs to the feet, blurring of vision,
Astigmatism and numbness of from her hands to
prescribed with corrective forearms
lenses persistent although out the day
PAST MEDICAL
HISTORY
(-) Hypertension
(-) Diabetes mellitus
(-) Pulmonary Tuberculosis
(-) Thyroid
(-) Cancer
(-) Allergy
(-) Previous hospitalizations
(-) Previous surgeries
FAMILY MEDICAL
HISTORY
(+) Bronchial Asthma - Brother
(-) Diabetes mellitus
(-) Hypertension
(-) Lung disease
(-) Kidney disease
(-) Pulmonary tuberculosis
PERSONAL AND
SOCIAL HISTORY
● Non – smoker
● Non – alcoholic beverage drinker
● Denies illicit drug use
● Unemployed
● No recent travels
● No recent vaccinations
REVIEW OF
SYSTEMS
General (-) easy fatigability, (-) weight loss, (-) changes in appetite

Integumentary (-) rash, (-) petechiae, (-) erythema, (-) jaundice, (-) abnormal pigmentation
(-) alopecia

Head and Neck (-) tinnitus, (-) hearing loss, (-) dryness of the mouth, (-) head trauma,
(-) eye pain, (-) eye discharge, (-) voice hoarseness

Respiratory (-) dyspnea, (-) cough, (-) hemoptysis

Cardiovascular (-) chest pain, (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal
dyspnea

Gastrointestinal (-) abdominal pain, (-) melena, (-) constipation, (-) bowel incontinence
REVIEW OF
SYSTEMS
Genitourinary (-) dysuria, (-) oliguria, (-) tea-colored urine, (-) urinary incontinence

Musculoskeletal (-) myalgia, (-) joint swelling, (-) joint pains, (-) erythema

Endocrine (-) polydipsia, (-) polyuria, (-) heat or cold intolerance, (-) palpitation

Hematologic (-) easy bruisability, (-) pallor

Dermatologic (-) oral ulcers, skin discolorations

Psychiatric (-) depression, (-) sleep disturbance

PHYSICAL
EXAMINATION
GENERAL SURVEY: Awake, alert, conscious, coherent, ambulatory, not in cardiopulmonary distress

Vital Signs: BP: 130/80 mmHg HR: 70 bpm RR: 21 cpm Temp: 36.7°C

Anthropometric Measurement: Ht. 174cm Wt. 75 kgs BMI: 24.77 kg/m2

SKIN: Warm, moist skin, with good turgor, no petechiae, no purpura, no bruises
HEENT: Pink palpebral conjunctiva, anicteric sclera, no opacities, 2-3mm ERTL, (-) Exophthalmos, Moist
buccal mucosa, hyperemic posterior pharyngeal wall, tonsils hyperemic, No palpable cervical
lymphadenopathy, thyroid gland not enlarged, (-) Prominent sternocleidomastoid on inspiration,
(-) Jugular vein distention
CHEST AND LUNGS: No deformity, no retractions, symmetrical chest and chest expansion, trachea at
midline, equal vocal and tactile fremitus, clear breath sounds on both lung fields
PHYSICAL
EXAMINATION
HEART: Symmetrical chest expansion, no retractions, Dynamic precordium, apex
beat at the 5th LICS MCL, S1 is louder at the apex than S2 while S2 is louder at
the base than S1, regular rhythm, peripheral pulses 2+ on all extremities, (-)
murmurs, lifts, heaves, thrills
ABDOMEN: Soft, flat symmetrical abdomen, normoactive bowel sounds, no
hepatosplenomegaly, no palpable mass, no tenderness, tympanitic on
percussion, liver span 6 cm, smooth contour of liver, Traube’s space not
obliterated, no masses noted
EXTREMITIES: Pulses full and equal on all extremities, no cyanosis, no edema
PHYSICAL
EXAMINATION
NEUROLOGIC:
Cerebrum: Awake, coherent, no aphasia, oriented to time, place and person, able to
follow simple and complex commands and do simple calculation, intact immediate,
recent and remote memory

CEREBELLUM: Can do rapid alternating movements and fine finger movement.

There is no dysmetria on finger-to-nose and heel-knee-shin. There are no abnormal
or extraneous movements. Romberg is absent.
PHYSICAL EXAMINATION
- cranial nerves
CN II Pupils 2-3mm equally reactive to light, no visual field cuts
CN II, III (+) Direct and consensual pupillary light reflex, VA 20/30 bilaterally, Fundoscopic
exam is normal with sharp discs and no vascular changes.
CN III, IV and VI Primary gaze midline, full EOMs except on left lateral rectus muscles; no ptosis,
(+) diplopia on horizontal gaze
CN V V1 – V3 intact sensory; intact muscles of mastication
CN VII (+) Bilateral facial asymmetry
CN VIII Intact gross hearing, (-) Weber, (-) Rinne
CN IX and X Good swallowing, uvula midline, (+) gag reflex
CN XI Sternocleidomastoid and Trapezius 5/5, bilateral
CN XII Tongue midline on protrusion
PHYSICAL
EXAMINATION
Motor: Muscle bulk and tone are normal. There is no pronator drift of outstretched arms. No atrophy,
hypertrophy, or fasciculations. No involuntary movements. No spasticity or rigidity of extremities

Sensory: Light touch, pinprick, position

90% 90%
sense, and vibration sense are
decreased in toes bilaterally 70%. 70% 70%
Intact light touch, but pinprick, position
sense, and vibration sense over fingers
bilaterally by about 90%
PHYSICAL
EXAMINATION
Meningeal signs: Supple neck, (-) Kernigs, (-) Brudzinski

Pathologic Reflexes:
(-) Babinski
(-) Oppenheim
(-) Gordons
(-) Chaddocks
(-) Hoffmans
Salient
features
HPI:
- weakness of the lower extremities
- numbness of both upper extremities
- baggy eyelids and shallow right nasolabial fold
- blurring of vision
- Bell’s Palsy
Salient
features
Physical examination:
- full EOMs except on left lateral rectus muscles
- (+) diplopia on horizontal gaze
- (+) Bilateral facial asymmetry
- Muscle strength is 4/5
- Decrease muscle strength on Light touch, pinprick, position sense, and
vibration sense — decreased in toes bilaterally 70%
- pinprick, position sense, and vibration sense over fingers bilaterally by
about 90%
- Knee and ankle reflexes are absent
Guillain-barre
syndrome
INITIAL IMPRESSION
 Basis
● Weakness of the lower extremities
● Numbness of both upper extremities
● Baggy eyelids and shallow right nasolabial fold
● Blurring of vision
● Decrease muscle strength on Light touch, pinprick, position sense, and
vibration sense — decreased in toes bilaterally 70%.
● Knee and ankle reflexes are absent
● Full EOMs except on left lateral rectus muscles
● (+) diplopia on horizontal gaze
● (+) Bilateral facial asymmetry
Differentials
Myasthenia Gravis
Rule in Rule out

● Age ● Bilateral and flaccid weakness of

the limbs.

● Gender

● Weakness in characteristic
distribution: proximal limbs, neck
extensors, generalized
Differentials
Acute inflammatory demyelinating
polyradiculoneuropathy
Rule in Rule out

● Especially with prolonged back ● Bilateral and flaccid weakness of

pain the limbs.

● Sphincter disturbances ● Decreased or absent deep tendon

reflexes in weak limbs
 Ancillary
procedures and
course in the
ward
COURSE IN THE WARD
Subjective Objective Assessment Plan

(+) Lower extremity weakness Awake, conscious, and not in Guillain Barre Syndrome ● Admission to ICU
(+) Blurring of vision cardiorespiratory distress ● IV hydration (PNSS 1l at 30
(-) DOB GCS 15 (E4V5M6) gtts/min)
(-) Chest pain Vital signs: ● Cardiac monitor
(-) Headache ● 130/80 mmHg ● Pulse oximeter
(-) N/V ● 79 bpm ● IVIG 0.4g/kg per dose
● 21 cpm once a day for 5 days
● 36.9oC
PE: Workup:
● VA: 20/30 ● CBC, UA, Na, K, Cl, SGPT,
● Diplopia (horizontal gaze) TFT, BUN, Crea, CXR, Lipid
● Left lateral rectus muscle Prof, Plain Cranial CT Scan
weakness
● (+) Right facial asymmetry
● MMT of 4-/5 (lower ex)
● Diminished sensory
perception (upper &
lower)
● (-) ankle and knee reflexes
● (-) dysarthria or aphasia
 CBC Day 1 Normal Values

WBC 4.5 5 - 10
Findings
of the Neutrophil 0.48 0.40 - 0.60

Diagnostics Lymphocyte 0.45 0.20 - 0.40

Requested Hemoglobin 133 123 - 152

(Day 1)
Hematocrit 0.42 0.37 - 0.42

RBC 4.6 4.50 - 5.50

MCV 91.3 88 - 96

MCH 29.3 27 - 33

MCHC 321 330 - 360

RDW 13.2 12.7 - 22.70

MPV 7.1 4.5 - 7.5

Platelet 190 150 - 450

Findings of the
Diagnostics Requested
(Day 1)
Test Day 1 Remarks

Urinalysis ● Dark yellow, turbid ● Taken on 3rd day of

● Specific gravity 1.005 menstruation
● pH 6.5
● RBC 20-30
● Pus 3-5
● Protein - NEGATIVE
● Blood +3
● No casts
Findings of the
Diagnostics Requested
(Day 1)
Blood Chemistry Day 1 Normal Value

Creatinine 66 45.00 - 84.00

Blood Urea Nitrogen 2.4 2.14 - 7.14

SGPT 48.5 (H) 0.00 - 33.00

Potassium 3.89 3.50 - 5.10

Sodium 131 136.00 - 145

Chloride 97.1 (L) 98.00 - 107.00

Findings of the Diagnostics
Requested (Day 1)
Blood Chemistry Day 1 Normal Value

Total Cholesterol 193 <200

Triglyceride 207 (H) <150

LDL Cholesterol 121 (H) <100

HDL Cholesterol 30.50 (L) >65

Fasting Blood Sugar 95.33 74.06 - 109.02

HBA1C 5.2 <5.7

TSH 2.45 0.27 - 4.20

FT3 2.49 2.02 - 4.43

FT4 1.43 0.93 - 1.71

Findings of the
Diagnostics Requested
(Day 1)
Imaging Day 1

Chest X-ray (APL) ● Diaphragm and costophrenic sulci are

intact
● Heart and great vessels not enlarged

Plain Cranial CT Scan ● No evidence of an acute intracranial

hemorrhage or acute territorial
infarction
Findings of the
Diagnostics Requested
(Day 1)
Test Day 1

ECG ● NORMAL sinus rhythm

● Non-specific ST wave changes
COURSE IN THE WARD:
2nd Hospital Day
Subjective Objective Assessment Plan

● Decrease in the lower Awake, conscious, coherent and not in Guillain Barre Syndrome ● IVIG continued
extremity weakness cardiorespiratory distress ● EMG-NCV was ordered
● Blurring of vision GCS 15 (E4V5M6)

Vital signs:
● 120/80 mmHg
● 75 bpm
● 18 cpm
● 36.7oC

Initial workup: Normal findings except -

● Moderate elevation in
triglycerides and LDL

PE:
● Manual Muscle Testing - 4-/5 on
both lower Ex
● Diminished sensory perception
(upper and lower)
● +1 DTRs on biceps and triceps, 0
on ankles and knees (bilateral)
Findings of the Diagnostics
Requested (Day 2)
COURSE IN THE WARD: 3rd
Hospital Day
Subjective Objective Assessment Plan

Marked improvement of Awake, conscious, coherent and Guillain Barre Syndrome ● Transferred to regular
lower extremity weakness not in cardiorespiratory distress room
and blurring of vision GCS 15 (E4V5M6) ● IVIG continued
Vital signs:
● 130/80 mmHg
● 70 bpm
● 19 cpm
● 36.5oC

PE:
● MMT - 4/5 on both lower
Extremities
● Improved sensory
perception (upper and
lower)
● +1 DTRs on biceps and
triceps, ankles and knees
(bilateral)

EMG-NCV: confirmed GBS

(predominantly demyelinating
neuropathy-motor nerves)
COURSE IN THE WARD:
4th Hospital Day
Subjective Objective Assessment Plan

No subjective complaints. Awake, conscious, Guillain Barre Syndrome ● IVIG continued

coherent and not in ● Referred to Rehab
cardiorespiratory distress Medicine
GCS 15 (E4V5M6)

Vital signs: stable

PE:
● MMT - 5/5 on both
lower Ex
● No sensory deficit
● +2 DTRs on biceps
and triceps, ankles
and knees (bilateral)
Repeat Blood Chemistry
Results (Day 4)
Blood Day 4 Normal Value Blood Chemistry Day 4 Normal Value
Chemistry

Creatinine 52.5 45.00 - 84.00 Triglyceride - <150

Blood Urea 3.6 2.14 - 7.14 LDL Cholesterol - <100

Nitrogen
HDL Cholesterol - >65
SGPT - 0.00 - 33.00
Fasting Blood - 74.06 - 109.02
Potassium - 3.50 - 5.10 Sugar

Sodium - 136.00 - 145 HBA1C - <5.7

Chloride - 98.00 - 107.00 TSH - 0.27 - 4.20

FT3 - 2.02 - 4.43

Total - <200
Cholesterol FT4 - 0.93 - 1.71
COURSE IN THE WARD:
5th Hospital Day
Subjective Objective Assessment Plan

No subjective Vital signs: stable Guillain Barre ● IVIG continued

complaints. Syndrome ● Started on
PE: essentially Physical
normal Therapy
 COURSE IN THE WARD:
6th-12th Hospital Day
Subjective Objective Assessment Plan

No relapse of lower Physical assessment: Guillain Barre ● Discharge once

extremity weakness ● Normal with Syndrome physical
and blurring of vision.. MMT of 5/5 on rehabilitation
all extremities was completed
● 100% sensory
perception
● +2 DTRs
bilaterally
Final diagnosis

GUILLAIN- BARRÉ SYNDROME

Basis:
● Weakness of the lower extremities
● Numbness of both upper extremities
● Blurring of vision
● Bilateral facial asymmetry
● Absence of reflexes on ankle and knee
Guillain - barré
syndrome
- An acute, frequently severe and fulminant
polyradiculoneuropathy that is autoimmune in nature
- Males > Females
- Adults > Children
Clinical
manifestations
● Rapidly evolving areflexic motor paralysis with or without
sensory disturbance
● Ascending Paralysis
● Tingling dysesthesias
● Pain on neck, shoulder, back, or over the spine
● Autonomic involvement
Pathophysiology
Procedures and
ancillary tests
 CBC DAY 1 NORMAL
VALUES
Complete WBC 4.5 5 – 10

blood count NEUTROPHIL 0.48 0.40 – 0.60

LYMPHOCYTE 0.45 0.20 – 0.40

HEMOGLOBIN 133 123 – 152

HEMATOCRIT 0.42 0.37 – 0.42

RBC 4.6 4.50 - 5.50

MCV 91.3 88 – 96

MCH 29.3 27 – 33

MCHC 321 330 – 360

RDW 13.2 12.7-22.70

MPV 7.1 4.5 – 7.5

PLATELET 190 150 - 450

URINALYSIS

Test Day 1 Remarks

Urinalysis Dark yellow Taken on 3rd Day
Turbid of Menstruation
1.005
pH 6.5
RBC 20-30
Pus 3-5
Protein - NEG
Blood +3
No casts
BLOOD CHEMISTRY
Blood Chemistry Day 1 DAY 4 Normal Value
Creatinine 66 52.5 45.00 – 84.00
Blood Urea Nitrogen 2.4 3.6 2.14 – 7.14
SGPT 48.5 - 0.00 – 33.00
Potassium 3.89 - 3.50 – 5.10
Sodium 131 - 136.00 – 145
Chloride 97.1 - 98.00 – 107.00
Total Cholesterol 193 - <200
Triglyceride 207 H - <150
LDL Cholesterol 121 H - <100
HDL Cholesterol 30.50 L - >65
Fasting Blood Sugar 95.33 - 74.06-109.02
HBA1C 5.2 - <5.7
TSH 2.45 - 0.27-4.20
FT3 2.49 - 2.02-4.43
FT4 1.43 - 0.93-1.71
IMAGING

Imaging Day 1
Chest X Ray (APL) Diaphragm and Costophrenic sulci are
intact
Heart and Great Vessels not Enlarged
Plain Cranial CT Scan No evidence of an acute intracranial
hemorrhage or acute territorial
infarction
ECG

Test Day 1
ECG NORMAL Sinus Rhythm
Non-Specific ST Wave Changes
EMG-NCV
EMG-NCV Test Laterality Nerves Affected
Motor Latency Delayed Bilateral Median
Ulnar
Fibular
Tibial
F-Wave Bilateral Median
Ulnar
Partial Conduction Bilateral Tibial
Block
CMAP dispersed Left Fibular
H-reflex absent Bilateral Tibial
Sensory Latency Delayed Bilateral Median
(Right more than Left)

SNAP Reduced Bilateral Median

(Index and Palm)
Electrophysiologic Nerve
Localization
Diagnosis Predominantly a demyelinating neuropathy mainly involving motor nerves
Management

● Treatment initiated immediately

○ High dose intravenous immunoglobulin
■ 5 daily infusions (2 g/kg)
○ Plasmapheresis
■ 4-5 times over 7-10 days (40-50 mL/kg)
● If there is relapse
○ Brief retreatment with with same treatment
Management

Home Medication and Discharge Plan

● Advise patient to come back immediately if there is relapse of

symptoms
● Advise patient to exercise and give specific diet
○ High fat diet and exercise
● Give Vitamin D as supplement
○ Promotes oligodendrocyte progenitor cell differentiation
PROGNOSIS

● Approximately 85% achieve a full functional recovery within

several months to a year ○ 80% patients with GBS walk
independently at 6 months, and about 60% of patients attain
full recovery of motor strength by 1 year
● Mortality rate is <5%, usually results from secondary pulmonary
complications
● Worst in patients with severe proximal motor and sensory
axonal damage
PROGNOSIS

● Other factors that worsen the outlook for recovery are:

○ Advanced age
○ Fulminant or severe attack
● Delay in the onset of treatment
● Recovery in approximately 5-10% of patients with GBS is
prolonged, with several months of ventilator dependency and a
very delayed, incomplete recovery
 Thank you!
Reference: Harrison’s Principle of Internal Medicine, 20th edition