This case report describes a 65-year-old male farmer who presented with epigastric pain, vomiting, constipation and tiredness. He was later diagnosed with Guillain-Barré syndrome (GBS) after developing progressive weakness and sensory loss. Tests showed severe motor-sensory axonal polyneuropathy. He was treated with plasmapheresis and supportive care and showed improvement over time, being able to walk with support at discharge. GBS is an acute autoimmune disorder affecting peripheral nerves. This case highlights the importance of considering GBS in progressive weakness cases and initiating early immunotherapy.

1. SAVING THE NERVES
- A CASE REPORT
Dr.Navas Shareef
nasmbbs@gmail.com
DNB Family Medicine

2. • Conscious, oriented to
time, place and person.
• Pulse: 80/min, RR-
20/min
• BP:110/70 mm Hg
• GCS 15/15
• No PICCLE
1. Epigastric pain for 3
days
2. Vomiting 2 episodes
3. Constipation for 3 days
4. Tiredness
Cardiovascular
system:S1,S2 normal
Respiratory system: Bilateral
NVBS
Per abdomen: Epigastric
tenderness +, BS +
Neurological examination-
Grossly normal
CASE
DESCRIPTION
• 65 year old male
• Farmer
• No known
comorbidities

3. FLUID TOTAL COUNT- 3 CELLS/mm3
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
PROGRESSION
DAY 01
DAY 02
8AM
DAY 02
2PM
DAY 04
Admitted in ward as acute gastritis and
started Rx symptomatically
C/o severe pain neck, back, shoulder and
limbs. Tingling and dysasthesias in extremities.
Worsening of weakness of limbs
Emergency NCS and MRI spine done- shifted
to ICU………..
Intubated and started mechanical ventilation
DAY 30 ??????

4. HMF - Normal
Cranial nerves- within normal limits.
Motor System- Right Left
Bulk Normal Normal
Tone UL Flaccid Flaccid
LL Flaccid Flaccid
Power UL Proximal 5/5 5/5
Distal 3/5 3/5
LL Proximal 3/5 3/5
Distal 2/5 2/5
Plantars Flexor Flexor
DTR Biceps Brachioradialis Triceps Knee Ankle
Right - - - - -
Left - - - - -
Cerebellar system- within normal limits
Sensory system- Decreased sensation to touch, vibration in bilateral lower limbs.
Single breath count- 15 and showed progressive worsening

5. POLYNEUROPATHIES
 A/c intermittent porphyria
 GBS
 Tick paralysis
 Thallium poisoning
ACUTE MYELOPATHIES
 Spinal cord compressing
lesion
 Anterior spinal artery
syndrome
 Acute transverse myelitis
MOTOR NEURON DISORDERS
 Amyotrophic lateral sclerosis
NEUROMUSCULAR
JUNCTION DISORDERS
 Botulism
 Myasthenia gravis
 Lambert-Eaton
syndrome
DIFFERENTIAL DIAGNOSIS OF FLACCID PARAYSIS

6. SEVERE MOTOR-SENSORY AXONAL POLYNEUROPATHY OF
BOTH UPPER LIMB AND LOWER LIMB
NERVE CONDUCTION STUDY

7. CSF ANALYSIS
FLUID TOTAL COUNT- 3 CELLS/mm3
TOTAL PROTEIN- 240 MG/DL
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN

8. CONTRAST MRI LS SPINE
PATCHY NERVE
ROOT
ENHANCEMENT AT
THE LEVEL OF
CONUS & S1-S2
LEVEL

9.  Rapid progressive ascending paralysis.
 Preceding gastritis
 Nobladder involvement /No sensory level /
Nofever at onset
 MRI: Nerve root enhancement
 NCS: Motor sensory axonal neuropathy
DIAGNOSIS

10. GUILLAIN-BARRE SYNDROME ?
PROGNOSIS
GBS
HOW TO
INVESTIGATE AND
CONFIRM
WHICH
VARIANT
OF GBS
HOW TO TREAT
AND TREATMENT
BARRIERS

11. FLUID TOTAL COUNT- 3 CELLS/mm3
GUILLAIN BARRE SYNDROME
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
• Acute auto immune mediated polyradiculoneuropathy
• Overall world-wide incidence of 1 to 2 cases per 100,000
per year
• Most common preceding infection -Campylobacter jejuni
• Other agents –CMV, EBV, HIV and Zika virus
• Rarely after triggering event such as immunization, surgery,
delivery, trauma, and bone-marrow transplantation.

12. FLUID TOTAL COUNT- 3 CELLS/mm3
GUILLAIN BARRE SYNDROME
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
Molecular mimicry :All GBSresults from
immune responses to non self
antigens(infectious agents, vaccines) that
misdirect to host nerve tissue through a
resemblance of epitope
Neural targets are gangliosides.

13. IMMUNOPATHOGENSIS
Conduction
block-
FLACCID
PARALYSIS
Disrupts
cluster of sodium channels
Complement
mediated injury at
Paranodal axon –
glial junction
Anti GB1 ab
as part of
molecular
mimicry
GM1 on
nerve,
nodes of
Ranvier

14. FLUID TOTAL COUNT- 3 CELLS/mm3
CLINICAL FEATURES
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
• Progressive, fairly symmetric muscle weakness usually
starts in the legs
• Decreased or absent reflexes in affected arms or legs in
approx. 90% of patients at presentation and in all patients
as the disease progresses.
• Paresthesias in the hands and feet in >80% patients
• Pain in the back and extremities in 66% of patients
• Respiratory muscle weakness necessitating ventilator
support develops in 10 to 30%

15. ≥50%
Facial nerve palsies
50%
Oropharyngeal weakness
15%
Oculomotor weakness
70%
Autonomic dysfunction
 Wide fluctuation in BP:
Paroxysmal HTN &
orthostatic hypotension
 Diarrhea/Constipation
 Urinary retention
 Cardiac dysrhythmias
(mc- sinus tachycardia)
 Horner syndrome
 SIADH-Hyponatremia
CLINICAL FEATURES

16. UNUSUAL CLINICAL FEATURES
FLUID TOTAL COUNT- 3 CELLS/mm3
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
• Papilledema
• Hearing loss
• Meningeal signs
• Vocal cord paralysis
• Mental status changes
• Reversible posterior leukoencephalopathy syndrome

17. AIDP AMSAN
GULLAIN BARRY SYNDROME-VARIANTS
AMANMFS
Bickerstaff
encephalitis ParaparesisPharyngeal-cervical-
brachial weakness
DEMYELINATING AXONAL
OTHERS

18. LABORATORY FEATURES: EMG and NCS

19. LABORATORY FEATURES:
LUMBAR PUNCTURE - CSF ANALYSIS
FLUID TOTAL COUNT- 3 CELLS/mm3
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
Raised protein 45 to 200 or more mg/dL (0.45 to 2.0 g/L)
No pleocytosis. ie, <5 white blood cells/mm3
Albuminocytologic dissociation
Usually normal in <48 hrs.
Increased proteins at the end of firstweek
Think of HIV,CMV,Lymediseasein case ofpleocytosis.
Inflammation of nerve roots Increased permeability of
the blood-nerve-barrier CSF protein

20. SPINAL CONTRAST MRI
FLUID TOTAL COUNT- 3 CELLS/mm3
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
• Thickening and enhancement of the intrathecal
spinal nerve roots and cauda equina.
• MRI brain: Enhancement of the oculomotor,
abducens, and facial nerves may be seen.

21. FEATURES MAKES THE DIAGNOSIS OF GBS DOUBTFUL
FLUID TOTAL COUNT- 3 CELLS/mm3
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
• Sensory level (decrement or loss of sensation below a
spinal cord root level)
• Asymmetry of weakness
• Bowel and bladder dysfunction at onset
• Severe pulmonary dysfunction with little or no limb
weakness at onset
• Severe sensory signs with little or no weakness
• Fever at onset
• CSF pleocytosis with cell count >50/mm3

22. FEATURES MAKES THE DIAGNOSIS OF GBS DOUBTFUL
FLUID TOTAL COUNT- 3 CELLS/mm3
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
• Sensory level (decrement or loss of sensation below a
spinal cord root level)
• Asymmetry of weakness
• Bowel and bladder dysfunction at onset
• Severe pulmonary dysfunction with little or no limb
weakness at onset
• Severe sensory signs with little or no weakness
• Fever at onset
• CSF pleocytosis with cell count >50/mm3

23. • ICU admission for close monitoring of respiratory,
cardiac and hemodynamic function.
• Ventilator support for neuromuscular respiratory
failure / Bulbar dysfunction (inability to clear secretions)
• Adequate pain control
• Prophylaxis for deep vein thrombosis
• Bladder and bowel care
• Physical and occupational therapy
• Psychological support
TREATMENT-SUPPORTIVE CARE

24. DISEASE-MODIFYING TREATMENT
IVIG vs PLASMAPHERESIS
• IVIG is not effective after 2 weeks of onset
• Plasma exchange can be done till 4 weeks of onset
• Both are equally effective
• Combination has no superior effect
• IVIG-thought as first choice since its easy to
administer
• Glucocorticoids are not beneficial

25. IVIG
 Rs. 15,849/- per 5gm 100ml
unit
 0.4gm per kg per day
 Average adult weighing 60kg
needs 5 unit per day for 5
days
 Total cost : 3,96,225/-
PLASMAPHERESIS
COST
 Rs. 512/- 450ML FFP UNIT
 50ml per kg per day
 Average 8 unit per day for
5 days
 Total cost : 20,480/-
AFFORDABILITY

26. PLASMAPHERESIS
8 UNIT FFP (50ml/kg) PER DAY FOR 5 CONESCUTIVE DAYS @ 40ML/MINUTE
1 LITRE NORMAL SALINE@ 40ML/MINUTE
HEPARIN 2000 IU PRIMING + 1000 IU/HOURS INFUSION
CALCIUM GLUCONATE 10% , 2 AMPOULE IN 50ML NS
DAILY 2 LITRE PLASMA EXCHANGE VIA DIALYSIS CATHETER FOR 5 DAYS
S/E – Hypotension, hypo prothrombinemia, bleeding, arrhythmia

27. IVIG
USE SEPARATE IV LINE
REFRIGERATED BOTTLE SHOULD BE BOUGHT TO ROOM TEMP
SLOW INUSION FOR THOSE WITH RENAL INJURY
START SLOWLY @ 25-50ML/HOUR AND INCREASE UPTO 100ML /HOUR
DAILY 0.4GM PER KG FOR 5 DAYS (Total:2000MG)
S/E – Anaphylaxis, Thrombophlebitis, Aseptic meningitis,
Hyper viscosity syndrome, Renal failure in dehydrated patients

28. FOLLOW UP
*Came to ER as a case
of GASTRITIS and later
diagnosed to have
GBS-AMSAN variant
ADMISSION POINT
TREATMENT PHASE
CONDITION AT DISCHARGE
FOLLOW UP-1 & 2 MONTH
*Mechanical ventilation
*PLASMAPHERESIS
*Intensive supportive care
*Vitally stable,
*Walk with support
*On Foley catheter
for urinary retention
*Patient was able to
ambulate sooner than
Predicted
*No residual muscle
weakness or autonomic
dysfunctions.

29. FLUID TOTAL COUNT- 3 CELLS/mm3
TAKE HOME MESSAGE
GLUCOSE- 82 MG/DL
NEUTROPHILS- NIL
NO ORGANISMS SEEN
• DTR examination for any type of weakness/ tiredness.
• Don’t hesitate to start immunotherapy in geriatric
group
• Mortality is determined by quality of ICU care
• Plasmapheresis is much cheaper compared to IVIG
• Do not use steroid
• Earlier the initiation of IVIG/PE, faster the recovery