Emergency Medicine Training – Guillain Barre Syndrome

Guillain Barre Syndrome
Yesterday, May 22, 2007, 8:06:36 AM | rss@youtube.com (garythedo)

I picked up that next chart and saw the chief complaint was rash after taking prednisone. Sounded straight forward. The patient was a 16 year old female who looked like she was feeling fine and with no visible rash when I walked in the room. Her mother told me that after taking the prednisone she broke out in hives and so they gave her Benadryl, and now the rash was gone. Great, I thought, I love it when patients treat themselves appropriately. Nothing left for me to do but give her my blessing to go home. She looked fine and had a negative physical exam while laying on the gurney. On my way out the door I asked the patient’s mother the reason she was taking Prednisone, was it because she has been have some type of recurrent rash? “No”, she answered, “It is because she can’t move.” That stopped me in my tracks. Can’t move? What does that mean? This question lead me down the rabbit hole. It turns out that the patient started having symptoms 2 weeks ago with extremity tingling and neck pain. She was seen in the ER and had neck x-rays which were negative and then followed up with her doctor and had an out patient MRI of her neck that was negative. She had her symptoms progress to weakness and cramping pain in her extremities. It did not seem to her that her symptoms were ascending but seemed to involve the proximal muscles of her hips and shoulders more then the distal muscles. The mother also told me that sometimes she would get facial symptoms with drooping eye lids or slurred speech. She told me that the longer she is up doing something the stronger she feels (as opposed to Myasthenia Gravis—where patients get weaker with repetitive movements) Her doctor started her on prednisone to see if it would help her symptoms because according to the mother he was worried that her symptoms were being caused by a virus. Her physical exam showed proximal muscle (MM) weakness. She could not sit up on her own, but once she was standing she could walk—but was somewhat off balance. She had to swing her legs around to the outside when she walked because of hip flexor weakness. Her cranial nerves were all intact except she had symmetric facial MM weakness and could not smile or puff out her checks. She could not smile or raise her eyebrows. Her reflexes were present 1+ hard to elicit bilateral biceps reflexes and 1-2+ bilateral patella reflexes. The interesting thing about her patella reflexes is that it seemed that there was a delay between when I would strike her knee and when it would move. It seemed to respond slowly. Almost the opposite effect of reflexes in severe hypothyroidism (where there is a delay in the relaxation phase). I could not get ankle reflexes. It turned out that this patient did in fact have Guillain-Barre syndrome (GBS). She had a high protein on her CSF tap during her hospitalization and was treated with IV IG. I thought that this would be a great opportunity to review Guillain-Barre and how it can present in children.

Author: garythedo
Keywords: Guillain Barre Syndrome Emerency Medicine Department Letter
Added: May 22, 2007

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