Fahi, a 2-year old girl, presented with weakness in her lower and upper limbs over the past 3-4 days. Her examination found decreased muscle tone and strength in all limbs along with absent reflexes. A provisional diagnosis of Guillain-Barré syndrome was made based on her symmetrical motor weakness and lack of sensory involvement. Investigations including a normal CSF study supported this diagnosis. She was started on supportive care and immunoglobulin treatment and instructed to monitor for progression of symptoms or complications. Further testing was planned to confirm the diagnosis.

1. Welcome to
clinical meeting
Dr. Shukur Ullah
DCH (student)
Bangladesh Institute of Child Health

2. Particulars of the patient
• Name : Fahi
• Age : 2 years
• Sex : Female
• Address : Chadpur
• Date of admission : 01.09.2017
• Date of examination: 03.09.2017
• Informant : Mother

3. Chief complaints
• Weakness in both lower limbs with inability
to walk for 3 days.
• Weakness in upper limbs for 1 day.

4. History of present illness
According to the informant mother, Fahi was
completely well 3 days back.Then she
developed symmetrical, ascending weakness
in both lower limbs which caused her unable to
walk. The day before admission, she
developed weakness in both upper limbs.
Mother also complained of irritability for 3 days.

5. History of present illness
With these problems, they visited a
physician and were referred to DSH for
better management. Following admission,
she got some injectable and oral
medications with little improvement. Now
irritability has been regressed.

6. History of present illness
There were no history of breathing or
feeding difficulties, fever, convulsion, loss of
consciousness, trauma or recent
vaccination. Her bowel and bladder
functions were normal. There was no history
of such type of illness in the locality.

7. History of past illness
There was no significant past illness.
Birth history
She was delivered normally at term with
average birth weight without any
complication. Her postnatal period was also
uneventful.

8. Milestones of development
Age appropriate.
Feeding history
She was on exclusive breast feeding upto
6 months of age then adequate
complementary feeding was started. Now
she is on family diet.
Immunization history
Immunized as per EPI schedule.

9. Treatment History
Nothing significant

10. Socio-economic history
The number of family members are 3. Her
father is a shopkeeper. He is the only earning
person in his family and his monthly income
is 12,000 taka (4,000 tk/person). Mother is a
housewife .
Family history
Fahi is the only issue of a non
consanguineous parents. Parents are healthy.
There was no history of similar illness in his
family.

11. Fahi, 2yrs old girl

12. General examination
• Appearance : Ill looking
• Decubitus : Supine position
• Anemia : Mild
• Jaundice : Absent
• Cyanosis : Absent
• Clubbing : Absent
• Leuconychia : Absent

13. General examination
• Ear, nose, throat : Normal
• Eyes : Normal
• Oral cavity : Normal
• Edema : Absent
• Dehydration : Absent
• Bony tenderness : Absent
• Skin survey : BCG mark present

14. General examination
• Lymph nodes : Not palpable
• Skin survey : BCG mark present
• Signs of meningeal irritation : Absent
• Spine : Normal
• Vital signs
-Pulse : 96/min, regular
-BP : 90/50 mm Hg
-Temp : 990 F
-RR : 24/min

16. General examination
• Anthropometry:
Weight : 11.2 kg
Length : 89 cm
OFC : 47 cm
Wt for age -0.8 Normal
Wt for length -1.7 Normal
Length for age +0.85 Normal

17. Systemic examination
Nervous system
• Higher psychic function : Normal
• Cranial nerves : Intact

18. Motor system
Traits Upper limbs Lower limbs
Muscle bulk Normal Normal
Tone Hypotonic Hypotonic
Power Grade 2/5 Grade 0/5
Reflex All deep reflexes
are absent
All reflexes are
absent
Plantar-
Equivocal
Gait &
Co-ordination
Could not be
elicited
Could not be
elicited

19. Nervous system
• Sensory functions : Normal
• Autonomic functions : Normal

20. Respiratory system
• Inspection: RR : 24/min, no subcostal or
intercostal recession
• Palpation : -Trachea : Centrally placed
-Apex beat: Left 5th ICS just medial
mid clavicular line
-Chest expansibility : Normal
-Vocal fremitus : Normal
• Percussion note: Resonant on both sides

21. • Auscultation:
-Breath sound : Vesicular
-Added sound : Absent
-Vocal resonance : Normal
Other systems revealed no abnormality.

22. Salient features
Fahi, a 2 years old immunized girl presented
with symmetrical, ascending weakness in both
lower limbs for 3 days associated with inability
to walk and irritability. She had also weakness
in both upper limbs for 1 day. There were no
history of breathing and feeding difficulties,
fever, convulsion, recent immunization,
trauma, bowel-bladder incontinence or such
type of illness in the locality.

23. Salient features
She was Ill looking, conscious, co-operative
having normal vital signs. Spine was normal.
She had symmetrical lower motor neuron
lesion in all 4 limbs in the form of hypotonia,
loss of power (grading 0/5 in the lower limbs
and 2/5 in the upper limbs) and areflexia.
There were no features of sensory,
autonomic, respiratory or bulbar
involvement.

24. Provisional diagnosis
Guillain-Barré Syndrome

25. Differential diagnoses
1. Transverse myelitis
2. Poliomyelitis

26. Investigations
• CBC
Hb : 11.9 gm/dl
TC : 14,500/mm³
DC : N-56%, L -40%, M-02%,
E- 02%
Platelet : 4,80,000/mm³
• Stool culture: 2 samples were sent to NPL
at 24 hours interval.

27. Investigations
• CSF study (7 days after onset of illness)
Amount : 2 ml
Color : Clear
Total cell count : 02/mm³
Lymphocytes - 100%
Sugar : 60 mg/dL
Protein : 200 mg/dl
Gram stain & AFB: No microorganisms
were found

28. Final diagnosis
Guillain-Barré Syndrome

29. Management
• Notification
• Counseling
• Monitoring
 Pulse, BP, RR
 Progression of paralysis
 Breathing difficulty
 Swallowing difficulty
 Speech difficulty
 Bowel and bladder habit

30. Management
• Supportive:
 Maintain nutrition
 Change posture 2 hourly
Physiotherapy (After subsiding pain)
• Specific:
Human immunoglobulin- 400mg/kg/day
for 5 days
• Follow up

32. Investigation plan
• Sural nerve biopsy
• Spirometry
• Nerve conduction velocity
• EMG
• MRI of spinal cord
• Anti-ganglioside antibodies