Paralysed and bed-bound: A Case of GBS from the Emergency Room and How We Managed It!

A few months ago, I saw a patient in the emergency room—a young man, just in his late 20s, complaining of muscle weakness and numbness in his legs. He had a recent diarrheal infection that seemed mild, and he initially thought the weakness was due to post-viral fatigue. But within a matter of 2 days, his weakness quickly worsened—his legs became paralysed entirely, and when he came to us on the third day, his breathing was compromised. It was clear this wasn’t just any common condition. It was Guillain-Barré Syndrome (GBS). The worst part? GBS can progress from mild muscle weakness to complete paralysis and respiratory failure in a matter of days—making it one of the most dangerous neurological emergencies.

What Is Guillain-Barré Syndrome (GBS)?

Guillain-Barré Syndrome is a rare but serious autoimmune disorder where the body’s immune system attacks the peripheral nervous system (PNS), particularly the nerve roots. This leads to demyelination—the loss of the protective sheath around the nerves—which causes muscle weakness, numbness, and, in severe cases, paralysis.

GBS typically begins with ascending weakness, meaning the symptoms start in the legs and progress upward to affect the arms and respiratory muscles. Respiratory failure is a significant risk, requiring ventilator support in critical cases.

The Danger of GBS: What Can Happen?

Guillain-Barré syndrome is not a condition that can be ignored. Without proper and rapid treatment, it can lead to:

●  Complete Paralysis: The muscle weakness can ascend to paralysis, rendering the patient completely immobilised. If left untreated, paralysis can affect the breathing muscles, leading to respiratory failure and potentially death.

●  Loss of Sensation: Patients can experience numbness or a sensation of “pins and needles,” particularly in their feet, which can spread as the condition progresses.

●  Cardiovascular Complications: GBS can affect the autonomic nervous system, leading to blood pressure fluctuations, heart arrhythmias, and tachycardia.

●  Inability to Move or Breathe: In severe cases, GBS can leave a patient unable to breathe on their own without a ventilator and entirely dependent on medical equipment for survival.

The Approach to Guillain-Barré Syndrome

The neurologist uses a planned diagnostic process when a patient shows symptoms that could indicate GBS. The diagnosis is confirmed, and other possible causes of increasing acute weakness are ruled out using a set of diagnostic tests and a thorough clinical examination. This is the standard method: 

1. Clinical Evaluation:

● Progression of Symptoms: A detailed assessment is done to confirm the ascending nature of the weakness (from legs to arms).

● Recent Infections: Since GBS is often preceded by viral infections, such as gastrointestinal infections (Campylobacter jejuni), respiratory diseases-*/ (such as the flu or COVID-19) and even Dengue fever, the doctor will inquire about these recent illnesses.

● Weakness and Reflexes: Weakness typically begins in the legs and progresses to the arms, and deep tendon reflexes may be absent or diminished.

2. Diagnostic Tests:

● Lumbar Puncture (Spinal Tap): A key test in diagnosing GBS, it checks for albuminocytologic dissociation, which is an increase in protein in the cerebrospinal fluid (CSF) without a corresponding increase in white blood cells.

● Electromyography (EMG) and Nerve Conduction Studies (NCS): These tests assess nerve conduction velocity and can detect demyelination in affected nerves.

● Blood Tests: To rule out other causes of weakness, such as electrolyte imbalances, and check for signs of infection or autoimmune triggers.

3. Differential Diagnosis: Guillain-Barré syndrome can be easily mistaken for other conditions. Some of the major differentials include:

● Myasthenia Gravis: A neuromuscular condition causing muscle weakness, but it typically affects ocular muscles first, unlike GBS.

● Polyradiculoneuropathy: Similar to GBS, it may have a more gradual onset and less demyelination.

● Spinal Cord Diseases (e.g., transverse myelitis): These conditions can present with weakness and sensory loss, but they typically cause spinal cord lesions that differ from GBS lesions.

Management of Guillain-Barré Syndrome

Early diagnosis and quick treatment are important for preventing complications and improving recovery. Treatment typically includes:

1. Plasmapheresis (Plasma exchange):

● In severe cases, plasmapheresis is performed to remove autoantibodies from the bloodstream, which are attacking the nerves.

● This treatment has been shown to shorten the disease duration and reduce disability.

2. Intravenous immunoglobulin (IVIg):

● IVIg therapy is used to modulate the immune system by providing healthy antibodies, which help prevent further nerve damage.

● This therapy is generally used when plasmapheresis is not available or feasible.

3. Respiratory Support:

● If the patient is unable to breathe on their own due to important diaphragm muscle damage, ventilator support is needed.

4. Physical Rehabilitation:

●After the acute phase, physical therapy is important for restoring muscle function, strength, and mobility.

5.  Monitoring for Complications:

● Close monitoring for cardiac arrhythmias, autonomic dysfunction, and breathing difficulties is essential during the acute phase of GBS.

How we managed our patient

We quickly assessed the patient in the emergency and ruled out other differential diagnoses. We did NCS, which revealed a demyelinating pattern (initial NCS may also be normal) and did a lumbar puncture, which revealed increased protein and ruled out infections. Once the diagnosis was confirmed, without any delay, we started our patient on IVIG therapy, following which the patient had 70-80% improvement within a week. The patient was started on active physiotherapy, and within 2 weeks of discharge, his weakness improved to almost 95%. The patient is now back to leading a normal, active life. However, not all patients are that fortunate. Timely diagnosis and treatment are very important.

Myths About Guillain-Barré Syndrome

Myth 1: Guillain-Barré Syndrome is always caused by vaccinations.
Fact: While GBS can occur after vaccination, it’s extremely rare, and the risk of GBS after vaccination is far lower than the risk of GBS after a viral infection like the flu or COVID-19.

Myth 2: Guillain-Barré Syndrome is fatal in all cases.
Fact: While GBS can be deadly due to respiratory failure and paralysis, if patients receive early treatment, then most of them can recover. The mortality rate has greatly decreased in the past few years due to advancements in care.