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CASE PRESENTATION GBS

CASE PRESENTATION GBS. By Dr. S. B. Sulehria Assistant Professor East Medical Ward KEMU/Mayo Hospital. BIODATA. Name:Abdul waheed Age:25y Sex:male Religion:Muslim Address:Mughal poora.Lahore Mode:Emergency DOA:07/04/12.

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CASE PRESENTATION GBS

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  1. CASE PRESENTATIONGBS By Dr. S. B. Sulehria Assistant Professor East Medical Ward KEMU/Mayo Hospital

  2. BIODATA • Name:Abdul waheed • Age:25y • Sex:male • Religion:Muslim • Address:Mughal poora.Lahore • Mode:Emergency • DOA:07/04/12

  3. Presenting Complaints • Pain in lower limbs=2weeks • Weakness of both upper and lower limbs=1&1/2 week

  4. HOPC • My patient non-diabetic and non hypertensive was in his usual state of health 2 weeks back when he felt pain in lower limbs.pain was not localized,mild to moderate in intensity,no aggravating factor but relieved on taking medicaton.Then one and half week back patient started having weakness of both lower limbs which started from feet and and later involved legs and now weakness has progressed to both the upper limbs.The weakness is equal in both sides.

  5. HOPC Cont…. Patient is unable to move his limbs even.There is no urinary or fecal incontinence.Patient has no h/o diarrhea or respiratory tract infection.There is no h/o fever.

  6. Systemic Inquiry • GIT: appetite normal,no change in bowel habits • Resp: not significant • CVS:no h/o orthopnea,dyspnea or chest pain • Musculoskeletal system: no h/o joint pain or swelling. Muscular weakness is present

  7. Past History • No H/O hypertension,ischemic heart disease,diabetes,asthma,TB,Hepatitis

  8. Family History • Mother is hypertensive and diabetic • No h/o ischemic heart disease,asthma or tuberculosis

  9. Personal History • Patient is not an addict,sleep and appetite normal,non smoker

  10. Socioeconomic History • Patient belongs to a poor family background

  11. Differential Diagnosis • Guillian Barre Syndrome • Myelopathy • Diphtheria • Lyme disease • Vasculitic neuropathy • Botulism

  12. General Physical Examination • A young Male well oriented in time,place and person lying comfortably on the bed with vitals Pulse:72/min RR:16/min BP:100/60 Temp:99F Pallor -ve,jaundice-ve,facial puffiness and pedal edema-ve,clubbing,koilonychia-ve,lymph nodes not palpable

  13. GIT • Inspection: On inspection there abdomen is normal in shape,moving with respiration and there is no visible abnormality • Palpation: On palpation there is no tenderness,rebound tenderness,and no palpable viscera • Percussion:No shifting dullness or fluid thrill present • Auscultation:Normal bowel sounds

  14. CVS • S1+S2+0 • No added heart sound or murmur heard

  15. Respiratory System • Normal Vesicular breathing with no added sound

  16. CNS • GCS: 15/15 • Higher mental functions are intact • Speech is normal

  17. Motor System • Bulk is b/l normal and comparable in all four limbs • Tone is decreased in all four limbs • Power is 0/5 in both the lower limbs and 1/5 in both the upper limbs • Deep tendon reflexes are absent • Plantars are b/l non responsive

  18. Sensory System • Intact • Cerebellum: Normal • SOMI: negative • Cranial Nerves: intact • Pupils are b/l reactive

  19. INVESTIGATIONS • CBC: HB:12.4g/dl WBC:9700 PLT:458000/mm3 HCT:38.7 MCV:86.7 MCH:34 MCHC:34.5

  20. INVESTIGATIONS (Cont…) • LFTs: ALT:27 AST:38 ALP:276 T.BIL:1.0 RFTs:Normal U/C: Normal

  21. INVESTIGATIONS (Cont….) • USG Abdomen: Normal • CXR: Normal • CSF Analysis: Proteins: 250mg/dl Glucose:67mg/dl Cells:5/mm3 all lymphocytes EMG and NCS: acute polyneuropathy with predominantly demyelinating features

  22. Final Diagnosis

  23. Guillian Barre Syndrome

  24. Introduction • It is an acute, frequently severe and fulminant polyradiculoneuropathy that is autoimmune in nature. • Males are at 1.5 times high risk for GB syndrome than females • Incidence is 1 case per million per month in USA and Canada

  25. Antecedent Facts • App 70% of cases have a h/o respiratory tract or the gastrointestinal infections • Compylobacter Jejuni is cultured in upto 30% of the cases • Other possible associations are with CMV, EBV, HHV, Mycoplasma pneumoniae Also associated with lymphomas, HIV seropositive individuals and SLE.

  26. Symptoms and Signs • Complaint of weakness often having a proximal emphasis and symmetric distribution. • Frequently involving arms and often one or both sides of the face. • Muscles of respiration and deglutition may also be affected. • Sensory symptoms include distal parasthesias and dysesthesias.

  27. Autonomic Disturbances • Common and may be severe • Tachycardia • Cardiac irregularities • Hypo or hypertension • Abnormalities of sweating,pulmonary dysfunction and impaired sphincter control

  28. Subtypes of GBS

  29. Laboratory Features • CSF findings Raised proteins( 100-1000mg/dl) Transient increase in CSF WBCs

  30. EMG and NCS • Demyelinating types: prolonged distal latencies, conduction velocity slowing, evidence of conduction blocks and temporal dispersion of compound action potentials. • Axonal types: Reduced amplitude of the compound action potentials

  31. Diagnostic Criteria For GBS • Required: 1.progressive weakness of 2 or more limbs due to neuropathy 2.Areflexia 3.Disease course < 4 weeks 4.Exclusion of other causes(e.g vasculitis,toxins,botulism,diphtheria, porphyria,localized spinal cord or cauda equina syndrome

  32. Diagnostic Criteria For GBS • Supportive 1. Relatively symmetrical weakness 2. Mild sensory involvement 3. Facial or other cranial N involvement 4. Absence of fever 5. Typical CSF profile 6.Electrophysiologic evidence of demyelination

  33. Treatment • IVIG 400mg per kg per day for five days • Plasmapharesis 40-50ml per kg plasma exchange four times over a week. • Glucorticoids have not been found effective.

  34. Ventilatory Support • Decreasing forced vital capacity • Intubation considered if FVC< 15ml/kg • Dyspnea evident • Oxygen saturation is decreasing • Low dose heparin to prevent PE

  35. THANKS

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