Guillain-Barre syndrome: A case report
Subin
Nursing Supervisor, Kauvery Hospital, Hosur
Introduction
Guillain-Barre syndrome (GBS) is a neurological disorder in which the body’s immune system mistakenly attacks part of its peripheral nervous system—the network of nerves located outside of the brain and spinal cord.
GBS can range from a very mild case with brief weakness to nearly devastating paralysis, leaving the person unable to breathe independently. Fortunately, most people eventually recover from even the most severe cases of GBS.
After recovery, some people will continue to have some degree of weakness. Guillain-Barre syndrome can affect anyone. It can strike at any age (although it is more frequent in adults and older people) and both sexes are equally prone to the disorder. GBS is estimated to affect about one person in 100,000 each year.
The exact cause of GBS is not known.
What we do know is that the affected person’s immune system begins to attack the body itself. It is thought that, at least in some cases, this immune attack is initiated to fight an infection and that some antigens on infecting organisms resemble those on nerve cells, which, in turn, also become targets of attack.
Since the body’s own immune system does the damage, GBS is called an autoimmune disease (“auto” meaning “self”). Normally the immune system uses antibodies (molecules produced in an immune response) and special white blood cells to protect us by attacking infecting microorganisms (bacteria and viruses).
In Guillain-Barre syndrome, however, the immune system mistakenly attacks the healthy nerves. The illness s usually start a few days or weeks following a respiratory or gastrointestinal infection. Occasionally surgery will trigger the syndrome. In rare cases vaccinations may increase the risk of GBS.
Patient information
Age :51years
Sex: Male
History of present illness: After going home previous night he had some numbness on left hand at 10pm. Then weakness extended to both lower limbs followed by upper limb. During this time he also developed breathing and swallowing difficulty.
Past history: patient is deaf and dumb. He was recently admitted with left epididymo orchitis, urethral stricture, phimosis with chronic balanoposthitis and discharged previous day of admission.
Family history: No illness Past medical history: Nil
Past surgical history: s/p circumcision and cystoscopy
On Examination
On arrival he was conscious and oriented, neck flexion- grade 1 to 2 present, and grade one power of both upper and lower limbs. His tone had reduced in all 4 limbs.
Vitals were stable, but he had accelerated hypertension.
He was shifted to ICU for further management.
As per neurologist advise, MRI brain taken, It showed periventricular and subcortical white matter ischemic changes,
MRI Cervical Spine showed mild cervical spondylotic changes in c4 and c5., mild posterior bulging in c5 and c6.
On the subsequent days his breathing pattern worsened. In the view of impending respiratory arrest, he was intubated and connected to ventilator support.
Also, he progressed to areflexia followed by dystonia. Consultant advised to do plasma exchange.,
Progressively he developed sepsis, due to prolonged hospital stay and ventilator support. He was advised tracheostomy.
After 4 cycles of plasma pheresis he had good progress. He was weaned from ventilator support and tracheostomy closure was done after 6 days. Later on he was shifted without any support to ward.
Nursing assessment and clinical assessment: On admission he was conscious and oriented, pupils equal reacting to light 2mm, muscle power was grade 1 for all 4 limbs, his oxygen level was not maintained and he was too tachypic also.
General condition
Vital signs: BP 120/80mmhg, PR :86/mts, SpO2 :98% on room air
Neurological assessment
GCS :15/15
Motor: lower limb power 4, and upper limb power 3
Sensory: conscious and oriented, obeys commands
Diagnostic test
NCS Report:
Motor conduction study shows prolonged distal latency of both median, left ulnar, right peroneal and both tibials, nerves. there was slowing of conduction velocity of both median nerves, conduction block was noted in right peroneal & right tibia nerves.
Sensory conduction study showed prolonged latency of both ulnar &right superficial peroneal nerves, there was showing of conduction velocity noted in both ulnar nerves.
F – waves were absent in both median, both ulnar, right peroneal &right tibia nerves.
Impression
The clinical presntation It fulfilled the Albert Kelly electrophysiological criteria for acute Demyelopathy ? polyneuropathy
Gram stain CSF: very few pus cells and no organism were seen
CSF analysis:
Glucose: 176 mg/dl
Micro Protein: 26 mg/dl
Cell Count :20 cells /micro/L
Cell Type Neutrophils: 40%
Lymphocytes :60% (Predominant Lymphocytes Seen.
MRI Brain: it showed periventricular and subcortical white matter ischemic changes
MRI Cervical Spine: it showed mild cervical spondylotic changes in C4 and C5., mild posterior bulging in C5 and C
Medical management & Specific treatment
Plasma exchange was done. He was intubated and connected to mechanical ventilator. after 4 days couldn’t be weaned, so directly gone to tracheostomy.
He was on antibiotics, anti-hypertensive, corticosteroids, analgesics, vitamin tablets and bronchodilators
Monitoring and prognosis
During discharge he was mobile and obeying to oral command
Nursing Management
1. Assessment and Monitoring
- Neurological Assessment: We assessed for the patient’s Muscle strength and reflex assessment.
- Hourly Monitored Vital Signs
2. Respiratory Management
- Monitor Respiratory Status: Assess for signs of respiratory distress or difficulty breathing, particularly if the diaphragm or other respiratory muscles are involved.
- Incentive Spirometry: Encouraging deep breathing exercises to prevent atelectasis and promote lung expansion.
3. Immune Therapy
- Plasma Replacement done to remove antibodies from the blood to decrease inflammation.
- Corticosteroids were added to reduce inflammation.
4. Pain Management
- Opioid Analgesics were prescribed for pain control.
5. Physical Therapy
- Positioning: Proper positioning and padding can help to prevent discomfort and injury caused by muscle weakness.
6. Nutrition Support
- Parenteral Nutrition: Feeding has started through Nasogastric tube
7. Psychosocial Support
- Encourage Family Involvement: Family members should be educated on the course of the disease, expected recovery trajectory, and how they can help care for the patient.
Patient education and discharge planning
During discharge he was conscious and oriented, muscle power upper limb – 3, lower limb – 4
Rehabilitation: Advised limb physiotherapy and medication follow up
Respiratory Monitoring: Education has provided to patient and relatives, regarding how to do spirometry effectively. Along with breathing and coughing exercise.
Follow up: He has to review in OPD after 15 days in Neurology department.
