30 - Guillain-Barre Syndrome Flashcards Preview

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Flashcards in 30 - Guillain-Barre Syndrome Deck (20):
1

Case 3

- 26 y/o white male with progressive limb weakness and numbness
- Noted numbness in palms 11 days ago with hands feeling “swollen and prickly”.
- 2 days later, same feelings under toes.
- 3 days later has difficulty climbing stairs, rising from a chair, cannot wash hair because he cannot keep arms over head.
- Constipation
- Numbness inside mouth and foods taste salty

So far we know that there is both sensory and motor neuropathy plus autonomic (constipation)

Seems to involve both upper and lower extremities

2

What is important to focus on when thinking about a diagnosis for this patient?

It is an ACUTE onset

Think: PAT PAT

3

Describe the past medical history of this patient

- No health problems
- Severe GI “flu” with diarrhea for 3 days one month ago

Some viral or bacterial etiology could have caused this

4

Medications and allergies

- Denies medications
- Denies allergies to environment, foot, drugs

5

Describe the social history of this patient

- Denies tobacco and alcohol
- Works as a custodian
- Volunteer fireman

Work place exposure to toxic cleaners?

6

Describe the physical exam in this patient

- Appears ill and is profusely diaphoretic
- BP: 140/110; Pulse: 116; Resp: 18, Temp: 98.0
- Lungs are clear to auscultation
- Cardiac exam normal
- Orientated x 3
- Unable to stand on toes, but can stand on heels (indicates a CNS problem)
- Unable to arise from a chair without pushing up with his arms
- Hand grips are weak bilateral
- Decreased touch, temperature, vibration below knees with profound loss of proprioception in toes bilateral
- Normal pin sensation
- Knee and reflexes are 0/4 bilateral
- Babinski sign is downgoing (normal)

BOTH large and small fiber neuropathy

7

What is on the differential list for this case?

Acute
- PAT PAT

Chronic
- A DUMB MMedIcAl BLmOG to CHARt Infections

Things that are possible...
- Bacterial meningitis-raised neutrophils
- Viral meningitis-raised lymphocytes
- Subarachnoid hemorrhage-elevated RBC
- Guillain-Barre-normal WBC
- Multiple sclerosis-raised lymphocytes

8

What else would you want to get for this patient?

- A1c
- CBC
- CMP
- Tox screen
- Lumbar puncture

9

CBC and CMP were normal. Went ahead with a lumbar puncture...

**** KNOW THIS ***

Lumbar puncture results
- WBC = 1
- RBC = 0
- Glucose = 67
- Protein = 88

Normal levels
- WBC =

10

What is the significance of the CSF findings?

- Elevated protein in the absence of white cells (so-called albumino-cytologic dissociation) suggests a demyelinating polyneuropathy
- Elevated protein in the absence of white cells (so-called albumino-cytologic dissociation) suggests a demyelinating polyneuropathy

11

Are the pateints signs and symptoms localized to the CNS or PNS?

There are signs and symptoms of both
- Ability to stand on heels but not toes suggests a problem with the spinal cord (CNS)
- However, hyporeflexia, negative Babinski, and distal sensory loss in a stocking-glove distribution more strongly suggest PNS problem

12

What would you expect muscle tone to be?

Flaccid due to lower motor nerve dysfunction due to a peripheral neuropathy

13

Why are the reflexes diminished?

- Hyporeflexia is seen with a peripheral neuroapthy and suggests a problem with the sensory neuron, dorsal column motor neuron, synapsis or muscle

14

Why was he constipated, tachycardic and diaphoretic?

All are signs of autonomic nerve dysfunction of the autonomic fibers of the PNS

15

What is the most likely diagnosis?

Guillain-Barre syndrome

This is acute inflammatory demyelinating polyneuropathy (AIDP)

In this case, since it is a young healthy guy and the onset was so acute, I think PAT PAT would take precedence over the other slower onset

16

What is the prognosis?

Good

Need to monitor - they are susceptible to cardiac and respiratory (ventilation) issues

There is a good chance of a full recovery and only 35% will have residual effects

Most of the motor/sensory/autonomic functions will come back, but not all of these symptoms will

17

What is the treatment?

Filter the blood (plasmaphoresis)

IV immunoglobulins

Close medical support for respiratory and cardiac

18

What might nerve conduction studies show?

Demyelinating etiology
- Prolonged distal sensory and motor latencies
- Diffusely decreased nerve conduction velocities
- Findings are due to severe demyelination of peripheral nerves, which slows conduction of action potentials

19

What about the diarrhea?

Suggests a previous bacterial infection or viral gastroenteritis, which precedes syndrome in 50% of patients

Guillain-Barre syndrome is commonly preceded by this

20

How does Guillain-Barre differ from multiple sclerosis?

- G-B is acute with PNS demyelination
- MS is chronic, with exacerbations and remissions, and is due to CNS demyelination