WBR0007

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Author Anonymous (Edited by Will Gibson and Alison Leibowitz)
Exam Type USMLE Step 2 CK
Main Category Internal medicine
Sub Category Gastrointestinal, Neurology, Infectious Disease, Gastrointestinal, Infectious Disease, Neurology
Prompt A 32-year-old man is brought to the emergency room by his wife for progressive loss of sensation and motor function of his lower extremities over the past month. The patient can no longer walk and must be carried onto the exam bed. He denies any recent history of trauma and the only illness he can recall consists of an episode of nausea, vomiting, and diarrhea 3 months ago, from which he recovered fully without medications. On exam, motor strength is 1/5 in both legs and deep tendon reflexes are impaired. What is the most appropriate next step in treatment of this patient?
Answer A Admission to the hospital and intravenous infusion of immunoglobulin.
Answer A Explanation [[AnswerAExp::IVIG is an effective disease-modifying therapy for Guillain-Barré syndrome.]]
Answer B Admission to the hospital and infusion of continuous drip dexamethasone.
Answer B Explanation [[AnswerBExp::Glucocorticoids, once considered a mainstay of GBS therapy, have been shown to be ineffective in randomized trials.]]
Answer C [[AnswerC::Outpatient therapy consisting of metronidazole (Flagyl) and follow-up the next day.]]
Answer C Explanation [[AnswerCExp::Metronidazole is a commonly prescribed antibiotic with activity against anaerobic bacteria and protozoa. It is the drug of choice for mild-to-moderate Clostridium difficile infection. The patient in this vignette has Guillain-Barré syndrome, a late complication of gastrointestinal infections most commonly caused by Camplyobacter jejuni. The patient no longer has any gastrointestinal infection and antibiotics would not improve the course of his disease.]]
Answer D [[AnswerD::Outpatient therapy consisting of a tapered regimen of oral prednison and follow-up the next week.]]
Answer D Explanation [[AnswerDExp::Because many patients will require respiratory support, the patient must be monitored closely as an inpatient. Furthermore, glucocoritcoids have demonstrated to be ineffective in randomized trials.]]
Answer E Admission to the intensive care unit and intubation when inevitable respiratory collapse occurs.
Answer E Explanation [[AnswerEExp::While many Guillain-Barré syndrome patients will eventually require admission to the intensive care unit (ICU), not all patients will require ICU monitoring and disease-modifying therapy should be initiated first.]]
Right Answer A
Explanation [[Explanation::Guillain-Barré syndrome (GBS) is a serious neurologic disease, in which the patient must be monitored as an inpatient because of its high likelihood for progression to respiratory failure (mechanical ventilation is required in 30% of patients). The main modalities for disease modifying treatments are plasmaphoresis and intravenous infusion of immunoglobulin (IVIG). These two treatments independently decrease the length of time until patients can walk by approximately 50 percent. The mechanism of IVIG in Guillain-Barré is not fully understood, but seems function by modulating immune activation.

Educational Objective: IVIG is an effective disease-modifying therapy for Guillain-Barré syndrome.
References: Double-blind trial of intravenous methylprednisolone in Guillain-Barré syndrome. Guillain-Barré syndrome Steroid Trial Group. Lancet. 1993;341(8845):586-90.]]

Approved Yes
Keyword GBS, Paralysis, [[WBRKeyword::Guillain-Barré syndrome]], Campylobacter, Bacteria, Autoimmune, Autoimmunity
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