A Case of Guillain-Barre Syndrome Preceding Multiple Sclerosis

Overview

Case Presentation

A 19-year-old woman was presented with acute weakness of limbs and unsteady gait which progressed to facial weakness in 2 days. She developed symptoms over 2 weeks and was dependent at presentation.

Medical History

  • The patient had watery diarrhea and recurrent vomiting that lasted for 3 days.
  • A week later, she developed acute proximal weakness, tingling and numbness of the upper and lower limbs with unsteady gait.
  • This quickly progressed to facial weakness.
  • Other medical history: Insignificant.

Clinical Exam

Her physical examination was unremarkable.

The neurological examination revealed:

  • Bilateral lower motor neuron facial palsy
  • Generalized areflexia
  • Proximal weakness of the 4 extremities of Medical Research Council grade 3/5
  • Negative stretch signs
  • Loss of deep sensation with sensory ataxia
  • Normal superficial sensory examination

Laboratory evaluation: Normal

Nerve conduction study: Normal

Lumbar puncture (3rd day of weakness) for CSF examination: Protein was 233 mg/dL, no lymphocytes and normal glucose.

Oligoclonal bands in the CSF and blood: Negative

MRI brain and cervical spine with contrast: Normal

Diagnosis

The patient was diagnosed with Guillain-Barre Syndrome.

Treatment

  • The patient received 6 sessions of plasma exchange on alternate days.

Post-Treatment Outcomes

  • Near-complete resolution of the limb and facial weakness was observed.

Nerve conduction study showed:

  • delay in distal latencies
  • slowed nerve conduction velocities
  • prolonged F wave supporting peripheral demyelination

2nd Admission

After 3 months of discharge,

  • The patient again experienced repeated vomiting for 2 days, with no diarrhea or abdominal pain.
  • On 3rd day, she started to re-experience bilateral limb weakness and ataxia that progressed to respiratory distress.

Follow-up Clinical Evaluation

  • MRI: Multiple variable-sized bilateral T2-weighted hyperintensities involving the deep white matter and the cervicomedullary junction
  • Postcontrast studies: 2 contrast-enhanced lesions.
  • Anti-aquaporin-4 antibodies (ELISA), ANA, ANCA, anti-dsDNA antibodies, lupus anticoagulants, B2 microglobulin, anticardiolipin antibodies, C3, C4, angiotensin-converting enzyme, anti-Brucella antibodies, anti-HIV antibodies and pathergy skin test for Behcet’s disease: Negative

Preliminary Treatment:

  • With the diagnosis of the recurrent form of GBS, the patient received 6 sessions of plasma exchange with marked improvement.

CSF analysis revealed:

  • elevated IgG index (3.1)
  • positive oligoclonal bands.

After 1 month,

  • Development of acute right-sided hemiparesis and hemihypesthesia
  • Left sixth nerve palsy and bilateral positive Babinski sign.

Diagnosis

The patient was diagnosed with MS

Treatment

  • IV methylprednisolone 1 g for 5 days with marked improvement.
  • Subcutaneous interferon beta-1a as a disease-modifying treatment was administered.

Follow-up

  • The patient did not report any attacks for 18 months.

Adapted from:

  1. Hassan A, El-Mazny A, Saher M, Ibrahim Ismail I, Almuqbil M. Co-Occurrence of Guillain-Barre Syndrome and Multiple Sclerosis: A Rare Case Report. Dubai Med J 2021;4:31–35.