D M Green1, A H Ropper. 1. Department of Neurology, St Elizabeth's Medical Center, Boston, MA, USA. dgreen@queens.org
Abstract
BACKGROUND: The unpredictability of the early course of Guillain-Barré syndrome (GBS) makes it difficult to determine which patients' conditions will worsen under observation. Most large randomized treatment trials for GBS have used an inability to walk as the enrollment criterion. Consequently, little is known about the treatment of those patients with milder degrees of affection. OBJECTIVES: To determine the approximate frequency of mild GBS with the persistent ability to walk and to see if there were features that predicted that the illness would remain mild. SETTING: A registry of patients with GBS seen on the wards and in the neurology clinic from January 1,1992, to May 1, 2000, in a 400-bed community teaching hospital. PATIENTS: Twelve (4.7%) of 254 patients in our case series were able to walk throughout their illness. Eight had been treated with plasmapheresis or intravenous immunoglobulin; the others were observed without treatment. RESULTS: There was no age, sex, or seasonal preponderance in comparison with large case series that included cases of all severities. Nine of 12 patients had a preceding respiratory tract infection, 10 had paresthesias, 7 had prominent pain, and 9 had ataxia. Seven of 10 patients who were examined had normal cerebrospinal fluid protein levels. It took 8 days, on average, to reach the maximal degree of weakness. One additional treated patient, excluded from our case series, had mild weakness for the first 3 weeks and subsequently worsened with a relapsing course more typical of chronic inflammatory demyelinating polyneuropathy. Eleven patients demonstrated proximal, intermediate, or distal conduction block, and only 3 had a mild degree of denervation. There were no distinguishing clinical or electrophysiologic features between treated and untreated patients with mild GBS and, except for the mild degree of affection and the absence of substantial electromyographic changes of axonal disruption, there were no important differences between these mild cases as a group and patients who developed more severe GBS. CONCLUSIONS: Cases of mild GBS reach a clinical nadir in a similar time to those with more severe disease. Treatment may be unnecessary in patients who are able to walk during the second week of illness, but observation until approximately the eighth day seems appropriate to be certain that the illness does not progress. In all likelihood there are mild cases of GBS that never come to the attention of a neurologist.
BACKGROUND: The unpredictability of the early course of Guillain-Barré syndrome (GBS) makes it difficult to determine which patients' conditions will worsen under observation. Most large randomized treatment trials for GBS have used an inability to walk as the enrollment criterion. Consequently, little is known about the treatment of those patients with milder degrees of affection. OBJECTIVES: To determine the approximate frequency of mild GBS with the persistent ability to walk and to see if there were features that predicted that the illness would remain mild. SETTING: A registry of patients with GBS seen on the wards and in the neurology clinic from January 1,1992, to May 1, 2000, in a 400-bed community teaching hospital. PATIENTS: Twelve (4.7%) of 254 patients in our case series were able to walk throughout their illness. Eight had been treated with plasmapheresis or intravenous immunoglobulin; the others were observed without treatment. RESULTS: There was no age, sex, or seasonal preponderance in comparison with large case series that included cases of all severities. Nine of 12 patients had a preceding respiratory tract infection, 10 had paresthesias, 7 had prominent pain, and 9 had ataxia. Seven of 10 patients who were examined had normal cerebrospinal fluid protein levels. It took 8 days, on average, to reach the maximal degree of weakness. One additional treated patient, excluded from our case series, had mild weakness for the first 3 weeks and subsequently worsened with a relapsing course more typical of chronic inflammatory demyelinating polyneuropathy. Eleven patients demonstrated proximal, intermediate, or distal conduction block, and only 3 had a mild degree of denervation. There were no distinguishing clinical or electrophysiologic features between treated and untreated patients with mild GBS and, except for the mild degree of affection and the absence of substantial electromyographic changes of axonal disruption, there were no important differences between these mild cases as a group and patients who developed more severe GBS. CONCLUSIONS: Cases of mild GBS reach a clinical nadir in a similar time to those with more severe disease. Treatment may be unnecessary in patients who are able to walk during the second week of illness, but observation until approximately the eighth day seems appropriate to be certain that the illness does not progress. In all likelihood there are mild cases of GBS that never come to the attention of a neurologist.
Authors: James J Sejvar; Kim A Lindblade; Wences Arvelo; Norma Padilla; Kimberly Pringle; Emily Zielinski-Gutierrez; Eileen Farnon; Lawrence B Schonberger; Erica Dueger Journal: Am J Trop Med Hyg Date: 2010-04 Impact factor: 2.345