From Flu to Flaccid Paralysis: Guillain-Barré Syndrome in a Previously Healthy Young Male

Case Diagnosis: 26 yo male with progressive bilateral upper and lower extremity weakness diagnosed with Guillain-Barre Syndrome.

Case Description or Program Description: 26 yo service-connected male with acute onset non-traumatic bilateral upper and lower extremity weakness. Patient developed lower extremity weakness over 7 days, found to be Influenza A positive with CXR consistent with pneumonia at VA hospital. Denies difficulty swallowing or bulbar symptoms. No numbness/tingling in extremities. Lumbar puncture and EMG were not performed during hospitalization. Initial EMG was performed upon admission to inpatient rehabilitation, 1 month after symptom onset. Follow-up EMG 2 months later.

Setting: Inpatient Rehab

Assessment/Results: Initial physical exam:
UE: 4+/5 shoulder abduction, 4/5 elbow flexion, 4-/5 wrist extension, 3-/5 wrist flexion, 3-/5 finger abduction, 3/5 thumb abduction
LE: 4+/5 hip flexion, 4/5 knee flexion/extension, 1/5 dorsiflexion, 1/5 first toe extension, 2/5 plantar flexion.
Sensation intact b/l UE and LE
Reflexes: Achilles 0, all others 2+ b/l

Initial EMG of RUE/RLE: absent common peroneal motor response, profoundly decreased amplitudes of motor tibial, median, ulnar responses with mildly decreased motor conduction velocity(CV); normal sensory responses in UE and LE; marked abnormal spontaneous activity in UE and LE muscles examined without signs of reinnervation.

Follow-up EMG: improvement of amplitude of median and ulnar motor responses with mildly decreased CV; normal sensory responses; absent median F-response, mildly prolonged ulnar F-response.

These findings correlated with mild improvement in physical strength in upper and lower extremities.

Discussion (relevance): GBS typically presents as a demyelinating neuropathy, with possible late axonal changes. This patient’s presentation revealed early axonal changes, which is an unusual presentation for GBS. Axonal changes are typically associated with worse outcomes, slower and longer recovery times, as is the case for Acute Motor Axonal Neuropathy (AMAN), a form of GBS.

Conclusions: In GBS with demonstrable axonal changes on EMG, it is important to correlate findings with the physical exam throughout recovery.