Recognizing Guillain-Barré in the ED: Going Up Fast

-Case-

A 36-year-old man comes to the ED complaining of progressive weakness in his legs over the past few days. He says it started as tingling in his feet and has slowly moved upward. Now, he struggles to climb stairs and feels like his legs are “heavier.” He denies any trauma, but he did have some mild GI discomfort and diarrhea about a week ago. On exam, you note decreased strength in the lower extremities, diminished reflexes, and normal sensation.

The progression of this patient’s symptoms are key – particularly in the setting of his recent likely viral illness. What “can’t miss” pathology comes to mind?

-Evaluation-

Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy often triggered by infections, classically Campylobacter jejuni. It’s characterized by progressive, symmetric ascending weakness, typically starting in the lower extremities.

• Key Clinical Features:
  • Symmetric ascending weakness
  • Hyporeflexia or areflexia
  • Paresthesias (though not usually prominent)
  • Can progress to involve respiratory muscles or cranial nerves
  • Autonomic dysfunction (bradycardia, labile BP, arrhythmias)

• History Clues:
  • Recent viral or GI illness (especially diarrhea)
  • No fever or systemic symptoms during weakness phase

Diagnosis:

• Clinical diagnosis is key in the ED, but an LP can help!
  • LP fluid evaluation will reveal albuminocytologic dissociation, or elevated protein in the setting of a normal WBC
• Nerve conduction studies/EMG are needed for definitive diagnosis (never something that will happen while in the ED)

Red Flags to consider include rapid progression of weakness, difficulty swallowing or speaking, and/or dyspnea/reduced respiratory effort. In these cases, intubation for airway protection is often necessary.

-Management-

1. Admission:
   • ALL suspected GBS cases need neurology consultation and hospital admission
   • ICU if any signs of respiratory or bulbar involvement
2. Monitor closely for respiratory failure and autonomic instability!
3. Treatments (started inpatient) will include IVIG or plasmapheresis (both generally known to be equally effective)
   

-Fast Facts-

• GBS is an acute ascending paralysis with areflexia, often post-infectious
• Respiratory failure is the most feared complication → monitor closely
• IVIG or plasmapheresis = mainstays of treatment
• Autonomic dysfunction can be subtle but dangerous
• An early neurology consult is essential!
• LP is key for diagnosis – make sure you understand the key differences between GBS and meningitis:

GBS can be easily missed in its early stages, especially when patients present with vague complaints of “heavy legs” or tingling. Let this serve as a reminder to dig deeper – especially when weakness is symmetric, progressive, and paired with hyporeflexia. When the pattern fits, act early, consult neurology, and keep a close eye on patients’ breathing; things can go downhill fast!

Want to learn more? Read our in-depth study guide and listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

References:

1. Ropper AH, Samuels MA, Klein JP. Guillain-Barré syndrome. N Engl J Med. 1991;324(17):1208-1215. doi:10.1056/NEJM199104253241706
2. Van Doorn PA, Ruts L, Jacobs BC. Clinical features, pathogenesis, and treatment of Guillain-Barré syndrome. Lancet Neurol. 2008;7(10):939-950. doi:10.1016/S1474-4422(08)70215-1
3. Sejvar JJ, Baughman AL, Wise M, Morgan OW. Population incidence of Guillain-Barré syndrome: a systematic review and meta-analysis. Neuroepidemiology. 2011;36(2):123-133. doi:10.1159/000324710
4. Hughes RA, Cornblath DR. Guillain-Barré syndrome. Lancet. 2005;366(9497):1653-1666. doi:10.1016/S0140-6736(05)67665-9
5. Doets AY, Verboon C, van den Berg B, et al. Regional variation of Guillain-Barré syndrome. Brain. 2018;141(10):2866-2877. doi:10.1093/brain/awy232