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Definition
• acquired disorder of the peripheral nerve, progressive, symmetrical,usually ascending weakness
• Described best as a polyradiculoneuropathy
• Guillain-Barré syndrome (GBS) is a rare autoimmune neurologicaldisease in which the body’s immune system produces antibodies
against its own nerves, resulting in damage to them.
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Epidemiology 1 –3/100 000 population according to epidemiologicalstudies from Europe, USA, and Australia
male-to-female ratio of 1.5:1
incidence in children is lower, with estimatesbetween 0.4 and 1.3 cases per 100,000 per year
GBS can occur at any age but is rare in childrenunder the age of 2 years
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Etiology
Post-infectious• immune-mediated disease targeting peripheral nerves
• virulence of C jejuni is thought to result from the presence of specific antigens in its capsule that are shared with nerves
• CMV infections present as upper respiratory tract infections,
pneumonias, and nonspecific flulike illnesses
Administration of certain vaccinations
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Clinical manifestation
evolving areflexic motor paralysis withor without sensory disturbance
bulbar weakness with difficultyhandling secretions and maintaining an
airway
Autonomic involvement fluctuation inblood pressure, postural hypotension,
and cardiac dysraythmias
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Subtypes of GBS • commonest type of Guillain-Barré syndrome
• lymphocytic infiltration of the peripheral nerves and macrophage mediatedsegmental demyelination
Acute inflammatorydemyelinating
polyradiculoneuropathy
• Wallerian-like degeneration of motor axons exclusively
• rapidly progressive weakness, often with respiratory failure and usually goodrecovery.
• muscle action potential amplitudes are reduced
Acute motor axonalneuropathy
• axonal degeneration with no demyelination or inflammationAcute motor sensoryaxonal neuropathy
• ataxia, areflexia, and ophthalmoplegia
• Anti-GQ1b antibodies were found oculomotor nerve contained the highestconcentration of GQ1b gangliosides conduction block is the most likelymechanism of ophthalmoplegia.
Miller fisher syndrome
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Pathogenesis
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classic pathological findings in acute
inflammatory
IgG and activated complement bind tothe axolemma of motor fibers at thenodes of Ranvier, followed by formation
of the membrane-attack complex.
nodal lengthening is followed by axonal
degeneration of motor fibers withneither lymphocytic inflammation nordemyelination
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Follow up
J 10th 2013
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January, 10th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warmacral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T- piece O2 8L/I, SpO2 92-94%
Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 22222/222222
22222/22222
A Respiratory failure ec Guillain-Barré Syndrome with unstable respiratory system, infection and musculoskeletal
system
P Management:
- T-piece attached O2 8L/I SpO2 92-94%
- IVFD D5% NaCl 0,9%
- Inj Ranitidine 25 mg/12 hr/IV
- Inj Meropenem 800 mg/12 hr/ IV (day 15th)
- Inj Farmadol 220 mg/ IV (if needed)
- Inj dexamethasone 11 mg/8hr/IV
- Ambroxol syr 3 x 5cc
- Zamel syr 1 x cth
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr
- CVP/6hr
- Chest physiotherapy
Diagnostic Planning: - Lumbal puncture
- Check albumin, T3, T4, TSH
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Blood Gas Analysis Result Unit Referral
pH 7.459 7.35-7.45
pCO2 32.0 mmHg 38-42
pO2 134.7 mmHg 85-100
Bicarbonat 22.2 mmol/L 22-26
Total CO2 23.2 mmol/L 19-25
Base Excess -1.3 mmol/L (-2) - (+2)
O2 Saturation 99.1 % 95 – 100
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January, 11th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 22222/222222
22222/22222A Respiratory failure ec Guillain-Barré Syndrome with unstable respiratory system, infection and musculoskeletal
system
P Management:
- T-piece attached O2 8L/I SpO2 92-94%
- IVFD D5% NaCl 0,9% + Ca. glukonas 10 mEq 20 gtt/I micro
- Inj Ranitidine 25 mg/12 hr/IV
- Inj Meropenem 800 mg/12 hr/ IV (day 15th)
- Inj Farmadol 220 mg/ IV (if needed)
- Inj dexamethasone 11 mg/8hr/IV
- Ambroxol syr 3 x 5cc
- Zamel syr 1 x cth
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr
- CVP/6hr
- Chest physiotherapy
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Lumbar puncture Result Unit Referral
Color Serous Serous
LDH 31 U/L < 200
Total protein 36.00 mg/dL < 45
Total leucocyte 0.001 10³/uL < 3
Total erythrocyte 0.000 10³/uL
Glucose 96 mg/dL 40 – 76
pH 7.5 7 – 8
MN cell 100.0 %
PMN cell 0.0 %
Result immunoserology
Total T3: 0,60 ng/ml (0,8-2)
Total T4: 8,63 g/dl (5-14)
TSH: 0,478 IU/ml (0,27-4,2)
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January, 12th 2013 and January, 13th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 22222/222222
22222/22222A Respiratory failure ec Guillain-Barré Syndrome with unstable respiratory system, infection and musculoskeletal
system
P Management:
- T-piece attached O2 8L/I SpO2 92-94%
- IVFD D5% NaCl 0,9%
- Inj Ranitidine 25 mg/12 hr/IV
- Inj Meropenem 800 mg/12 hr/ IV (day 15th)
- Inj Farmadol 220 mg/ IV (if needed)
- Inj dexamethasone 11 mg/8hr/IV
- Ambroxol syr 3 x 5cc
- Zamel syr 1 x cth
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr
- CVP/6hr
- Chest physiotherapy
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January, 14th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 22222/222222
22222/22222A Respiratory failure ec Guillain-Barré Syndrome with unstable respiratory system, infection and musculoskeletal
system
P Management:
- IVFD D5% NaCl 0,9%
- Inj ceftazidine 500 mg/8hr/IV (day 1st)
- Inj Farmadol 220 mg/ IV (if needed)
- Ambroxol syr 3 x 5cc
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr
Diagnostic Planning:
Check electrolite
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January, 15th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 22222/222222
22222/22222A Guillain-Barré Syndrome
P Management:
- IVFD D5% NaCl 0,9%
- Inj ceftazidine 500 mg/8hr/IV (day 1st)
- Inj Farmadol 220 mg/ IV (if needed)
- Ambroxol syr 3 x 5cc
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr
Result of electrolyte:
Ca: 7,7 mg/dl
Na: 132 mEq/l
K: 3,6 mEq/l
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January, 16th 2013 and January, 17th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 33333/33333
22222/22222A Guillain-Barré Syndrome
P Management:
- IVFD D5% NaCl 0,9%
- Inj ceftazidine 500 mg/8hr/IV (day 1st)
- Inj Farmadol 220 mg/ IV (if needed)
- Ambroxol syr 3 x 5cc
- Nebule NaCl 0,9% 2,5cc/8hr - Diet 70 cc/kgBW/day 190 cc/3hr
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January, 18th 2013 - January, 20 th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 33333/44444
22222/22222A Guillain-Barré Syndrome
P Management:
- IVFD D5% NaCl 0,9%
- Inj ceftazidine 500 mg/8hr/IV (day 1st)
- Ambroxol syr 3 x 5cc
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr
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January, 21st 2013 - January, 22nd 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 44444/44444
22222/22222A Guillain-Barré Syndrome
P Management:
- IVFD D5% NaCl 0,9%
- Inj ceftazidine 500 mg/8hr/IV (day 9th)
- Ambroxol syr 3 x 5cc
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr - Physiotheraphy
Diagnostic Planning:
Check blood routine, electrolyte, LFT, RFT, glucose ad random
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Complete Blood Count Result Unit Referral
Hb 10.40 gr% 11.3 – 14.1
WBC 8.33 x 103/mm³ 4.5 – 13.5
RBC 3.97 x 106/mm³ 4.40 – 4.48
Hematocrite 31.90 % 37 – 41
PLT 387 x 10³/mm³ 150 – 450
MCV 80.40 fL 81 – 95
MCH 26.20 Pg 25 – 29MCHC 32.60 g% 29 – 31
RDW 17.00 % 11.6 – 14.8
MPV 8.80 fL 7.0 – 10.2
PCT 0.34
PDW 9.0
Neutrophil 44.70 % 37 – 80
Lymphocyte 39.50 % 20 – 40
Monocyte 13.90 % 2 – 8
Eosinophil 1.3 % 1 – 6Basophil 0.6 % 0 – 1
Liver Result Unit Referral
Total bilirubin 0.34 mg/dL < 1
Direct bilirubin 0.09 mg/dL 0 – 0.2
AST 26 U/L < 38
ALT 18 U/L < 41
Kidney Result Unit Refferal
Ureum 13.10 mg/dL < 50
Creatinine 0.24 mg/dL 0.32 – 0.59
Uric acid 2.9 mg/dL < 7.0
Electrolyte Result Unit Referral
Sodium 133 mEq/L 135-155
Calcium 9.2 mg/dL 9.2 – 11.0
Pottasium 4.1 mEq/L 3.5-5.5
Phosphor 6.2 mEq/L 3.4 – 6.2
Chloride 113 mEq/L 96-106
Magnesium 2.35 mEq/L 1.4 – 1.9
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January, 23rd 2013 - January, 25th 2013
S Weakness of both upper and lower extremities (+), fever (-)
o CNS Stable, sens: compos mentis,
Eye: isochoric pupil, light reflex (+/+), 2 mm
Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm
acral
Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-
piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and
providential retgen
Gastrointestinal Stable, soepel, normoperistaltic, clear NGT
Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000
Musculoskeletal Stable, edema (-)
physiology reflex: APR/KPR: +/+
pathology reflex: (-)
muscle strength: 44444/44444
22222/22222A Guillain-Barré Syndrome
P Management:
- IVFD D5% NaCl 0,9%
- Inj ceftazidine 500 mg/8hr/IV (day 9th)
- Ambroxol syr 3 x 5cc
- Nebule NaCl 0,9% 2,5cc/8hr
- Diet 70 cc/kgBW/day 190 cc/3hr - Physiotheraphy
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• Patient was discharged from hospital on25th January 2013 because his condition
of stability was improved. NGT waschanged. Family patient has beeneducated regarding to the method of using the NGT at home. Patient has beentold to be controlled at the policlinic of
neurology pediatric and get thephysiotherapy once per week.
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