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GBS Case Presentation.pptx
A 58-year-old man presented with progressive weakness in his lower limbs over 6 days along with difficulty swallowing and speaking. His symptoms progressed to involve his upper limbs as well. On examination, he had decreased strength and reflexes in all limbs along with facial weakness and impaired swallowing. Nerve conduction studies showed axonal and demyelinating changes. He was diagnosed with acute motor axonal neuropathy, a subtype of Guillain-Barré syndrome. He was treated with IVIG and supportive care and showed significant improvement in strength and reflexes on follow up.
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GBS Case Presentation.pptx
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- 2. Chief Complaints A58 Y/o Muslim male from Godhra, Poultry farmer by profession, belonging to lower socio-economic class, admitted on 28th of March presented with a chief complain of progressive weakness in both lower limbs for 6 days, difficulty in swallowing since 4 days, difficulty in speaking since 3 days.
- 3. History of PresentIllness Patient was relatively asymptomatic before 10 days when he developed diarrhoea for 1 day without fever or abdominal pain, without blood or mucus, which was self limiting. After 4 days he developed bilateral symmetrical lower limb weakness which he noticed in the form of difficulty in walking (requiring assistance/support for standing and walking). It gradually progressed in 2 days to an extent where he couldn’t stand up. The weakness extended upto the upper limbs from onset of weakness in 2 days in the form of decreased grasping strength and difficulty in moving upper limbs. He developed difficulty in swallowing since 4 days and difficulty in speaking since 3 days.
- 4. Negative history Patient hadno complaint of Bowel or bladder disturbance Fever, cough, chest pain, difficulty in breathing Abnormal movements Visual disturbance (double vision or blurred vision) Tingling, numbness Gabhraman, palpitation, blackouts (syncope) Muscle tenderness or joint pain Recent Injury or bite Compound ingestion
- 5. Past History Historyof chikungunya fever diagnosed in December 2021 for which analgesics were prescribed (pints and oral medications) History of recent COVID vaccination present on 3rd February, 2022. Vaccination was uneventful. (First Dose Taken) No history of BT. No history suggestive of TB.
- 6. Personal History Non significant FamilyHistory Non significant Drug History No past history of any drug allergy or daily intake of any medication
- 7. Differential Diagnosis Atthe end of history we have 58 y/o male patient with a case of bilateral ascending weakness of all 4 limbs with acute history which progressed over 4 days with bulbar involvement and no loss of sensations and no bladder involvement without difficulty in breathing. 1. Guillain Barré Syndrome 2. Infectious Polyradiculoneuropathy (HIV, CMV) 3. Periodic Paralysis
- 8. Examination Patient wasexamined after consent with proper light and exposure General condition was guarded Temperature was normal. Pulse was 82 in right radial artery with normal force, volume and tension. Blood pressure was 150/82 mmHg in right arm in supine position. Respiration is regular at 16 breaths per minute with no accessory muscle involvement. Respiratory excursion is normal (5cm)
- 9. General Examination Wellbuilt and properly nourished No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.
- 10. Systemic Examination Sincepredominantly nervous system has been involved. I would like to do CNS examination first. Higher function except speech was normal. Conciousness, behaviour, intelligence, memory, orientation was normal, no delusion or hallucination. Speech (flaccid dysarthria) was affected in the form of impaired labiodental and labial sounds. (b, bh, ph, ma etc.)
- 11. Cranial Nerve Examination There was no abnormalities in Cranial nerves I, II, III, IV, V, VI, VIII, XI and XII. Facial nerve There is bilateral symmetrical weakness in the muscles of the face. Patient is unable frown, close eyes completely, blow out his cheeks or show his teeth. Bell’s Phenomenon present. Absent Corneal and conjunctival reflex. Taste Sensations are normal. Lacrimation and salivation normal. Glossopharyngeal and Vagus nerves Uvula is in Midline. Diminished palatal arch movements. Absent gag reflex. Nasal Twang present.
- 12. Motor system examination Built normal, nutrition normal with normal muscle volume with loss of contour. Tone was decreased in all four limbs. Power assessed was as follows. (At the time of Admission)
- 13. Joint Right Left ShoulderFlexion 2 2 Shoulder Extension 3 3 Shoulder Abduction 3 3 Shoulder Adduction 3 3 Shoulder External Rotation 3 3 Shoulder Internal Rotation 3 3 Elbow Flexor 4(-) 4(-) Elbow Extensor 4(-) 4(-) Wrist Extensor 4 4 Wrist Flexor 4 4 Hip Flexor 3 3 Hip Extensor 2 2 Hip Abduction 3 2 Hip Adduction 3 3 Hip External Rotation 3 3 Hip Internal Rotation 3 3 Knee Flexor 2 2 Knee Extensor 4 3 Ankle Dorsiflexion 4(-) 4(-) Ankle Plantar flexion 5 5
- 14. Hand Gripwas decreased bilaterally. Neck Flexion 2 Neck Extension 5
- 15. No Respiratorymuscle weakness. Chest Excursion was normal ( 5cm ) SBC is more than 30.
- 16. Sensory system examination Fine touch normal Pain and Temperature normal Joint position and proprioception normal Pressure sensation normal
- 17. Refexes (superficial reflexes) Corneal and conjunctival reflexes Absent. Gag Reflex absent at the time of admission. Gag Reflex present today. Plantars are flexors. Abdominal Reflexes absent.
- 18. Deep tendon reflexes(at the time of admission) Muscle Right Left Supinator 0 0 Biceps 0 0 Triceps 0 0 Knee 0 0 Ankle 0 0
- 19. Cerebellar Function No evidenceof cerebellar dysfunction. Nose finger test, finger to finger test and nose finger nose test normal. No dyssynergia, tremors, dysdiadochokinesia. All cerebellar tests (including examination gait) couldn’t be performed due to predominant weakness in the lower limbs.
- 20. Gait Can’t beassessed as patient unable to walk. Neck and Back Normal Nerves and Vessels No nodularity, thickness or tenderness present over palpable nerves. Palpable vessel wall thickening absent. Peripheral arterial pulsations present in all 4 limbs.
- 21. Differential diagnosis atthe end of Examination 1. Gullain Barré Syndrome 2. Infectious polyradiculoneuropathy. 3. Periodic Paralysis
- 22. Provisional Diagnosis Anatomical Abnormality:- Acute polyradiculoneuropathy. Functional Abnormality:- Inability to stand up or swallow and difficulty in using both the upper limbs My provisional diagnosis is Ascending type of polyneuropathy with LMN type of VII, IX and X nerve palsy most likely Guillain Barré Syndrome.
- 23. Investigation Hb 15.70gm/dL TC 21100 /cmm DC 88/10/1/1 Platelet 2.31 lacs/cmm Urea 54 U/dL Creat 1.14mg/dL Bil 0.6/0.2/0.4 Na 134mEq/L K 4.4mEq/L Viral Markers Negative (HIV Negative)
- 24. NCV Nerve ConductionStudy of B/L Upper limbs and Lower limbs tested nerves shows predominantly Motor Axonal + Demyelinating Affection. Possibility of AMAN Variant of GBS likely.
- 26. Final Diagnosis Ascendingtype of Lower motor neuron type of weakness with VII, IX and X nerve palsy. Motor Variant (AMAN subtype) of GBS.
- 27. Treatment Patient wasstarted with IVIg at 2gm/kg body weight over 5 days. Supportive therapy including Antibiotics, Physiotherapy was also given.
- 28. MRC Sum ScoreToday (Power Assessment) Movement Right Left Shoulder Abduction 4 4 Elbow Flexion 4 + 4 + Wrist Extension 4 4 Hip Flexion 4 4 Knee Extension 4 3 Foot dorsiflexion 4 4 48
- 29. Deep Tendon ReflexesToday Muscle Right Left Supinator 2 2 Biceps 2 2 Triceps 2 2 Knee 1 1 Ankle 2 2
- 30. Facial weaknesshas improved and patient is able to swallow. Patient is able to lift his eyebrows and close his eyes. There is still some weakness in the form of him unable to blow out cheeks. Dysarthria has improved. Corneal and conjunctival reflexes have reappeared.
- 31. Prognosis There issignificant improvement in power of and slight improvement in the reflexes of the patient. Approximately 85% of patients of GBS achieve full recovery within several months to a year. Although minor findings on examination may persist and symptoms of fatigue may persist. Mortality rate is <5% in optimal settings; death usually results from secondary pulmonary complications.
Editor's Notes
- #4 Difficulty in swallowing was associated with pain
- #22 Thiamine Deficiency Adults with thiamine deficiency from nutritional deficiencies or chronic alcohol use typically present with a symmetric, distal motor and sensory polyneuropathy Lyme Disease Tick Paralysis HIV associated polyradiculoneuropathy (CMV Infection) Sarcoidosis May present with peripheral neuropathy or cranial neuropathy, elevated ACE level in blood or meningeal enhancement in Brain or Spine Imaging supports the diagnosis Leptomeningeal lymphoma may present with peripheral neuropathy but have other symptoms such as headache, Encephalopathy, or cranial nerve palsies. Early stage of transverse myelitis, sensory level on examination, early bowel and bladder dysfunction, elevated CSF count. Botulism Poliomyelitis Occult Snake Bite OP poisoning
- #32 Modified Erasmus Global Outcome Score (mEGOS) can be used to estimate the risk of being unable to walk at 6 months. (Our patient’s Score 8 implying 22% risk of being unable to walk unaided at 6 months) Risk factor for poor outcome Age>60 Rapid onset of weakness (<7 days from