Guillain-Barre syndrome (GBS) is a rare neurologic disorder caused by demyelination of the peripheral nerves. The cause of Gullain-Barre syndrome is unknown, but it may develop after a respiratory or gastrointestinal viral infection. Symptoms such as tingling, numbness, or weakness are often noted first in the legs, but this may be due to the fact that the legs bear more weight and have longer peripheral nerves.
In many cases, symptoms are present in the upper extremities at the time of diagnosis. Difficulty climbing stairs is often the first motor difficulty noted by the patient. Paresthesias are common, occurring in 80% of cases. Complete spinal cord sensory level (below which there is no voluntary motor or sensory function) or bowel or bladder difficulties should not be present; if they are, a spinal cord lesion should be ruled out.
Early on in the disease, abnormalities may only be noticed during a physical examination if a provider checks for a loss of DTRs and the patient’s ability to perform lunges.
Testing for Guillain-Barre syndrome often involves magnetic resonance imaging of the spine to rule out a cord lesion or cord compression. The differential diagnosis may include ruling out heavy metal toxicity, endocrine disorders, tick-borne paralysis, and Lyme disease. The diagnosis is usually made clinically and may be confirmed by testing to rule out other conditions (electrolyte abnormality) and/or finding of elevated protein on a delayed lumbar puncture. Treatment typically involves admission for intravenous immunoglobulin (IVIg) or plasma exchange under the direction of a neurologist.
A patient should be admitted to the intensive care unit if they are short of breath, unable to walk, or are having bulbar symptoms. Intubation may be required if forced vital lung capacity drops below 15 mL/kg. Therapy with steroids should be avoided, as this treatment does not help and can worsen weakness. Mortality has been estimated to occur in 5% of patients from severe dysautonomia or respiratory failure or from secondary sepsis or pulmonary embolism. Fortunately, 70% of people with Guillain-Barre syndrome eventually experience full recovery.
In this case, the patient’slumbar puncture test showed a red blood cell count of 1, a white blood cell count of 2, and cerebral spinal fluid total protein of 125 mg/100 mL, which was positive. The patient’s condition worsened until therapy started, but he did not need to be intubated.
It is important to know how to tailor a physical examination to the chief presenting complaint. Always check for clonus and DTRs in a patient with any complaint of lower extremity weakness. If strength seems normal, always have the patient perform more challenging activities like lunges.
Brady Pregerson, MD, is an emergency physician at Tri-City Medical Center in Oceanside, California and at Scripps Coastal Urgent Care in Oceanside, California.
Pregerson DB. Neurology weakness. In: Emergency Medicine 1-Minute Consult Pocketbook. 5th ed. 2017;5. http://www.erpocketbooks.com/emergency_medicine_reference_books/quick-essentials-emergency-medicine/