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.