Guillain-Barré syndrome classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Priyamvada Singh, MBBS [2]

Overview

There are several types of GBS, but unless otherwise stated, GBS refers to the most common form, acute inflammatory demyelinating polyneuropathy (AIDP). It is frequently severe and usually exhibits as an ascending paralysis noted by weakness in the legs that spreads to the upper limbs and the face along with complete loss of deep tendon reflexes. The other less common variants involve Miller Fisher syndrome, acute motor axonal neuropathy (AMAN), acute motor sensory axonal neuropathy(AMSAN), acute panautonomic neuropathy and Bickerstaff's brainstem encephalitis (BBE).

Classification

Acute Inflammatory Demyelinating Polyneuropathy

  • Commonest form of GBS, and the term is often used synonymously with GBS.
  • Caused by an auto-immune response directed against Schwann cell membranes.
  • Commonly preceded by a bacterial or viral infection.
  • Campylobacter jejuni is the commonest causative agent (positive in approximately 2 out of 5 patients).
  • Peripheral nerve demyelination is present. Symptoms generally resolve with remyelination.

Acute Motor Axonal Neuropathy (AMAN) [1]

  • Also known as Chinese paralytic syndrome
  • Prevalent in China and Mexico.
  • The disease may have seasonal variations.
  • Recovery can be rapid.
  • Due to auto-immune response directed against the axoplasm and nodes of Ranvier of peripheral nerves.
  • Anti-GD1a antibodies[2] are present. Anti-GD3 antibodies are commonly found associated with it.

Acute Motor Sensory Axonal Neuropathy (AMSAN)

  • It is similar to AMAN however unlike AMAN it also affects sensory nerves [3].
  • It is probably due to an auto-immune response directed against the axoplasm of peripheral nerves.
  • Recovery is slow and often incomplete.[4]

Pure Sensory

  • Rapid onset of sensory loss and areflexia in a symmetric pattern.
  • Lumbar puncture studies show albuminocytologic dissociation as seen with other GBS
  • Electromyography show characteristic signs of a demyelination.
  • Prognosis is usually good.

Miller Fisher Syndrome

  • Accounts for approximately 5% of GBS cases
  • Unlike Acute inflammatory demyelinating polyneuropathyit manifests as a descending paralysis
  • It usually affects the eye muscles first and presents with the triad of ophthalmoplegia (external) [5], ataxia and areflexia [6].
  • The ataxia predominantly affects the gait and trunk, with the limbs relatively spared.
  • Anti-GQ1b antibodies are present in 90% of cases [7].

Acute Panautonomic Neuropathy

  • Most rare variant of GBS
  • Prognosis may be poor because of its association with encephalopathy and cardiovascular involvement, and associated dysrhythmias.
  • Initial symptoms of lethargy, fatigue, headache can be present.
  • Common symptoms include impaired sweating, lack of tear formation, photophobia, dryness of nasal and oral mucosa, itching and peeling of skin, nausea, dysphagia, and constipation or alternating with diarrhea.
  • Autonomic symptoms like orthostatic hypotension, lightheadedness, blurring of vision, abdominal pain, diarrhea, dryness of eyes, and disturbed micturition can be seen.
  • Parasympathetic impairment (abdominal pain, vomiting, constipation, ileus, urinary retention, dilated unreactive pupils, loss of accommodation) may also be observed.

Bickerstaff's Brainstem Encephalitis (BBE)

  • Another rare variant of GBS
  • Associated with acute onset ophthalmoplegia, ataxia, disturbance of consciousness, hyperreflexia or Babinski's sign. * It can have monophasic or remitting-relapsing progression.
  • Neuroimaging with Magnetic resonance imaging (MRI) plays a critical role in the diagnosis.
  • Large, irregular hyperintense lesions located mainly in the brainstem, especially in the pons, midbrain and medulla can be seen.
  • Prognosis is good despite the initial severe presentation
  • It is commonly found associated with axonal Guillain–Barré syndrome suggesting some linking between the two disorders

References

  1. McKhann GM, Cornblath DR, Ho T; et al. (1991). "Clinical and electrophysiological aspects of acute paralytic disease of children and young adults in northern China". Lancet. 338 (8767): 593–7. PMID 1679153. doi:10.1016/0140-6736(91)90606-P. 
  2. Ho TW, Mishu B, Li CY; et al. (1995). "Guillain-Barré syndrome in northern China. Relationship to Campylobacter jejuni infection and anti-glycolipid antibodies". Brain. 118 ( Pt 3) (3): 597–605. PMID 7600081. doi:10.1093/brain/118.3.597. 
  3. Winer JB (2002). "Treatment of Guillain-Barré syndrome". QJM : Monthly Journal of the Association of Physicians. 95 (11): 717–21. PMID 12391383. Retrieved 2012-02-19. 
  4. Griffin JW, Li CY, Ho TW; et al. (1995). "Guillain–Barré syndrome in northern China. The spectrum of neuropathological changes in clinically defined cases". Brain. 118 ( Pt 3) (3): 577–95. PMID 7600080. doi:10.1093/brain/118.3.577. 
  5. Kimoto K, Koga M, Odaka M, Hirata K, Takahashi M, Li J, Gilbert M, Yuki N (2006). "Relationship of bacterial strains to clinical syndromes of Campylobacter-associated neuropathies". Neurology. 67 (10): 1837–43. PMID 17130419. doi:10.1212/01.wnl.0000244468.22377.6b. Retrieved 2012-02-19. 
  6. FISHER M (1956). "An unusual variant of acute idiopathic polyneuritis (syndrome of ophthalmoplegia, ataxia and areflexia)". The New England Journal of Medicine. 255 (2): 57–65. PMID 13334797. doi:10.1056/NEJM195607122550201. Retrieved 2012-02-19. 
  7. Chiba A, Kusunoki S, Obata H, Machinami R, Kanazawa I (1993). "Serum anti-GQ1b IgG antibody is associated with ophthalmoplegia in Miller Fisher syndrome and Guillain-Barré syndrome: clinical and immunohistochemical studies". Neurology. 43 (10): 1911–7. PMID 8413947. 

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