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Guillain-Barre syndrome
Symptoms of GBS
Symptoms often start in your feet and hands before spreading to your arms and legs.

At first you may have:

 numbness
 pins and needles

 muscle weakness

 pain

 problems with balance and co-ordination

These symptoms may continue to get worse over the next few days or weeks before they start
to slowly improve. In severe cases, you may have difficulty moving, walking, breathing
and/or swallowing.

Question:

34 year old lady presented with difficulty walking since last few days.
History, examination and management.
You are the FY 2 in GP clinic.

Dr: Hello Are you Mrs... I am Dr ... How can I help you ?
Pt: I am having weakness and numbness in my legs and hands and I am not able to walk
properly.
Dr: I see. Since when you started having these symptoms ( weakness spreads quickly that
within days or weeks in GBS compared to other neurological problems which can months to
progress) ? Last few days.
Dr: Do you how did these symptoms started ?
Pt:These numbness started in my feet and hands and now they are spreading up in the last
few days.
When do you get these symptoms – any particular time of the day or are they present
throughout ?
Dr: Did you have these symptoms all these days since it started or are there any days you did
not have symptoms ( Multiple sclerosis – sometimes they do not have symptoms) ? I had this
every day.
Dr: do you have these symptoms in both the legs and both hands or only one side hand and
leg ( GBS is bilateral) ? Both the arms and both legs.
Dr: Are the weakness is more severe in the evening ( Myasthenia) ? No
Dr: Do you have weakness anywhere else – like arms, face, neck ? No
Dr: Do you have any other symptoms ? Like what ?

Dr: Do you have any pains in arms, legs, back or anywhere in the body (GBS, vasculitis,
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polymyositis) ? I have pain in my back.

Where exactly in your back ? ... Since when ? Since last few days.
Dr: Do you have fever ( vasculitis) ? No
Dr: Do you feel hot and cold sensations in your legs ( no sensory loss in BGS, myasthenia
and polymyositis where as there is sensory loss seen in transverse myelitis,? Yes

[ ask symptoms from head to toe]

Dr: Any problem in your vision ( Multiple sclerosis, Mysthenia) ? No
Dr; Do you have any breathing difficulty ? No
Dr: Do you have any problem in speaking ? No
Dr: Do you have any problem in swallowing ? No
Dr: Do you have diarrheoa or constipation ? No
Dr: Do you have bowel or urine incontinence { BGS, Transverse myelitis ( seen early)}? No
Dr: Do you have any problem in balance or difficulty walking ( GBS) ? No

Dr: any changes in your food recently lie did you have food in restaurants or did you have
any canned food recently ( botulism) ? No

[ ask triggers for GBS – recent flu or bowel infections]

Dr: Did you have fever in the recent past ? Yes, I had flu three weeks ago.
Dr: Did you have diarrhoea recently ? No

Dr: Did you have this type of problem previously ? No

Dr: Do you have any medical conditions or have been diagnosed with medical conditions in
the past ? No
Dr: Are you taking any medications ? No
Dr: Are you allergic to any medications? No
Dr: Any family members have any medical conditions ? No
Dr: Thank you very much for all the information. Is there anything else you think may be
important for us to know ? I don’t think so.

Examination:
Check the NEWS chart for any temperature.
Dr: Mrs I need to examine you now. I need to do what we call as neurological examination.

Examiner may give the signs:

Power reduced in legs. ( Power was 3)

Reflexes will be reduced or absent in GBS, where as in Myasthenia and Botulism they will
be normal and hyperreflexia in Tranverse myelitis).
Pupil Normal size ( not dilated), Pupils reacts normally to light – in GBS
( Ptosis, dilated and non reactive pupils seen in Botulism)

Dr: Mrs.. I could see some weakness in your legs.

Investigations :
We need to do some tests to find out what exactly is causing these problems.
We will refer you to the specialist called Neurologist in the hospital.
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We need to do tests like Lumbar puncture ( where need to take some fluid from the lower
spine and test it)
[Elevated cerebrospinal fluid protein without elevated cell count. This may take up to 10
days from onset of symptoms to develop].
Also other tests what we call as Eletromyography and nerve conduction test which tests
muscle and nerve function. (Abnormal nerve conduction velocity findings, such as slow
signal conduction)

Examiner may or may not give results. Check for elevated Protein in CSF if CSF result is
given.

Diagnosis:
Dr: Mrs .... I think you have a condition what we call as Guillain Barre syndrome.
Do you have any idea about this ? No
Dr: Guillain-Barré syndrome is a very rare and serious condition that affects the nerves. It is
thought to be caused by a problem with the immune system, the body's natural defence
against illness and infection. Normally the immune system attacks any germs that get into the
body. But in people with Guillain-Barré syndrome, something goes wrong and it mistakenly
attacks and damages the coverings of the nerves and reduces nerve function ( condutcting
signals from brain to the muscles). This causes weakness in the muscles.
Do you follow me ? Yes but how did I get this ?

Dr: We do not know what exactly causes this problems. However, we think it is due to
previous infection like flu or diarrhoea. In your case you had flu recently. That could have
caused this problem.

Pt: Is there any treatment doctor?

Dr: We need to admit you to the hospital for the treatment. Neurologist will see you and tell
you about the treatment.

We will a medicine called Immunoglobulin through your veins – Immunoglobulin is made

from donated blood that helps bring your immune system under control.

 We may need to do a procedure called plasma exchange (plasmapheresis) – an

alternative to immunoglobulin where a machine is used to filter your blood to remove the
harmful substances that are attacking your nerves. Our Consultant will decide what is suitable
to you.

 Other treatment we may give are to reduce symptoms and support body functions,
such as painkillers.

 Most people need to stay in hospital for a few weeks to a few months.

Do you follow me ? Is that Okay ? Is there anything else you want to know ?
Pt: Will I improve after the treatment doctor?
Dr: Most people with Guillain-Barré syndrome make a full recovery, but this can take months
or even years.
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Some people won't make a full recovery and are left with long-term problems such as:

 being unable to walk without assistance

 weakness in your arms, legs or face, breathing or swallowing problem,

 numbness, pain or a tingling or burning sensation

 balance and co-ordination problems

 extreme tiredness

Therapies such as physiotherapy, occupational therapy and speech and language therapy

can help you recover and cope with any lasting difficulties.

Also we may need to put on machine to help with breathing and/or a feeding tube if it is
required if there is problem with breathing or swallowing problem in the future.

Pt: Will I die because of this problem ?

Dr: Most of the people recover from the condition completely. Very rarely only it is life
threatening. Any other question ?

Warning signs:

Dr: In the future after discharge from the hospital if you develop symptoms like

 difficulty breathing, swallowing or speaking

 can't move their limbs or face

 faints and doesn't regain consciousness within two minutes

This is a medical emergency and you need to be seen in hospital as soon as possible

So please come to the  A&E department immediately. Thank you.

Differential Diagnosis for GBS

Disease/Conditio Differentiating
Differentiating Tests
n Signs/Symptoms
Transverse myelitis Spinal cord disorders Cerebrospinal fluid (CSF)
including transverse myelitis analysis: pleocytosis with modest
present with asymmetric number of lymphocytes and
motor or sensory loss usually increase in total protein.
involving lower extremities,
Magnetic resonance imaging
early bowel or bladder
(MRI) shows focal demyelination
dysfunction with persistent
with possible enhancement at the
incontinence, and segmental
appropriate level.
radicular pain.
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Physical exam demonstrates

upper motor neuron signs
(hyperreflexia, positive
Babinski response) and a
sensory level.

Myasthenia gravis Early involvement of muscle Electrophysiological study shows

groups including extraocular, normal nerve conduction and
levator, pharyngeal jaw, neck, presence of decremental
and respiratory muscles. response to repetitive nerve
Sometimes presents without stimulation.
limb weakness.
Electromyogram (EMG) shows
Excessive fatigability and abnormal jitter and blocking.
variation of symptoms and
Edrophonium test is normally
signs through the day is
positive. However, many centers
common.
do not routinely perform this test
Reflexes are preserved, and because of potential side effects.
sensory features,
dysautonomia, and bladder
dysfunction are absent.

Lambert-Eaton Can be difficult to differentiate Electrophysiologic study: hallmark

myasthenic because of similar clinical is a low amplitude compound
syndrome (LEMS) characteristics. However, muscle action potential (CMAP)
some characteristics are after single nerve stimulus,
more typical for LEMS. These increase in CMAP amplitude after
include slower development voluntary contraction, or repetitive
of clinical symptoms, dry stimulation at high frequencies. [137]
mouth, lack of objective
sensory loss, rare
involvement of respiratory
muscle group, and
potentiation of reflexes after
exercise or contraction. 
Botulism History of ingesting food Electrophysiologic study: reduced
tainted with botulinum toxin.
amplitude of evoked muscle
potentials, increase in amplitude
Descending paralysis begins
with repetitive nerve stimulation
in the bulbar muscles then
and increased number of
the limbs, face, neck, and
myopathic units, which is atypical
respiratory muscles.
for GBS. 
Respiratory muscles are
involved with mild limb
weakness, and reflexes are
usually preserved.
Ptosis, dilated nonreactive
pupils are present. Dilated
nonreactive pupils are
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uncommon in GBS, but more

common in botulism.
Constipation is also a
characteristic feature of
botulism.
Polymyositis Presence of pain and muscle Elevated erythrocyte
tenderness usually in the sedimentation rate (ESR) and
shoulder and upper arm, creatine kinase (CK), normal
involvement of flexor neck nerve conduction study, and
muscle disproportionate to myopathic changes with
limb weakness, absence of fibrillation on EMG.
sensory symptoms,
Muscle biopsy shows muscle
preservation of reflexes,
fiber destruction and
absence of dysautonomia,
regeneration, and lymphocyte
and presence of skin lesions,
infiltrates. 
which are uncommon
presentation for GBS.
Vasculitic Common features include May have elevated ESR.
neuropathy painful asymmetric
CSF does not show
presentation of muscle
albuminocytologic dissociation.
weakness, uncommon
involvement of cranial nerves, Electrophysiologic study shows
respiratory paralysis, and evidence of denervation.
sphincter dysfunction.
Nerve biopsy shows signs of
Usually patients complain of inflammation and scarring. [137]
fever, fatigue, weakness, and
arthralgia. [137]