Guillain Barre Syndrome: A clinical observational… Sri Lanka Journal of Child Health, 2017; 46(3): 238-242

Guillain Barre Syndrome: A clinical observational study in Indian

paediatric patients
*Shikha Swaroop1, Bakul B Javadekar2

Sri Lanka Journal of Child Health, 2017; 46(3): 238-242

Abstract time of admission had a poorer prognosis than those

Background: Guillain Barre Syndrome (GBS) is the with involvement of only lower limbs.
most common cause of acute flaccid paralysis (AFP)
after nationwide poliomyelitis eradication measures Conclusions: In our study antecedent infection was
in India. AFP surveillance has increased the seen in 38% of patients. There was a 22% mortality
detection of cases. New modalities of management and demyelination NCV study was seen in 50% of
such as artificial ventilation and intravenous the expired patients. The prognosis was poorer in the
immunoglobulin (IVIG) are expected to increase older age groups. Patients with quadriparesis had a
survival of GBS patients. poorer prognosis than those with paraparesis.

Objective: To study the clinical presentation, DOI: http://dx.doi.org/10.4038/sljch.v46i3.8325

prognostic factors and outcome in GBS patients
admitted to a tertiary care centre in Gujarat, India. (Keywords: Guillain Barre Syndrome (GBS), nerve
conduction velocity (NCV), intravenous
Method: A prospective observational study was immunoglobulin (IVIG), outcome)
carried out in a tertiary care centre in Gujarat, India.
All paediatric patients with symmetrical onset of Introduction
weakness, flaccid paralysis and hyporeflexia, Guillain-Barre Syndrome (GBS) is an acute
admitted to the centre from March to October 2013, immune-mediated polyradiculoneuropathy
were included in the study. Patients with asymmetric characterized by rapidly progressive, symmetrical
weakness, isolated cranial nerve involvement and limb weakness with partial or complete loss of
upper motor signs were excluded. A detailed clinical reflexes1. It may be accompanied by sensory
history was taken and a systemic examination was deficits, autonomic dysfunction and respiratory
done. Nerve conduction velocity (NCV) study was insufficiency1. The clinical course comprises an
carried out. All patients received IVIG and other acute phase, followed by a plateau phase of variable
supportive measures. Accumulated data were duration, leading to spontaneous recovery and
compared to other similar studies. resolution of paralysis to a variable degree1.
Recovery can be hastened with plasma-exchange
Results: Eighteen paediatric GBS patients were and intravenous immune-globulin (IVIG) therapy1.
enrolled during the study period. An equal incidence After control of poliomyelitis, GBS has emerged as
of the disease was seen in all age groups. Males were the commonest cause of acute flaccid paralysis
more commonly affected. Antecedent infection was (AFP). The AFP surveillance system has improved
seen in 38%. Upper respiratory tract infection and the reporting of the cases. Further, the newer
fever were the most common. Most (66.7%) patients modalities of management made available by the
presented with weakness in both upper and lower government of Gujarat in the form of artificial
limbs. Mortality in our study was 22%. Some ventilation equipment and IVIG are expected to
prognostic factors such as demyelination NCV study improve the overall survival of these patients
was seen in half of the expired patients. The greater reporting to health care in Gujarat.
the age the poorer was the prognosis. Patients with
involvement of both upper and lower limbs at the Objectives
_________________________________________ • Clinical presentations in GBS patients
1
UN Mehta Institute of Cardiology and Research • Prognostic factors and outcome in terms of
Centre, India, 2Vadodara Medical College, India survival and death
*Correspondence: [email protected] • Morbidity in survivors
(Received on 20 December 2016: Accepted after
revision on 20 January 2017) Method
The authors declare that there are no conflicts of A prospective observational study was carried out in
interest a tertiary care centre in Gujarat state (Paediatric
Personal funding was used for the project. Department, Sir Sayajirao Gaikwad Hospital,
Open Access Article published under the Creative Vadodara). Approval of the study was obtained from
the Scientific and Ethical Research Committee,
Commons Attribution CC-BY License Medical College Vadodara. Sample size was

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Guillain Barre Syndrome: A clinical observational… Sri Lanka Journal of Child Health, 2017; 46(3): 238-242

decided on the basis of feasibility as it was a time Whilst 12 (66.7%) patients had motor weakness in
bound study, so all the patients admitted to the all 4 limbs, 06 (33.3%) had only lower limb
tertiary centre from March to October 2013 were weakness. Five (27.8%) patients had cranial nerve
included in the study. All paediatric patients with involvement and 8 (44.4%) had respiratory muscle
symmetrical onset of weakness, flaccid paralysis involvement requiring mechanical ventilation.
and hyporeflexia were included. Patients with Sensory system involvement and bladder bowel
asymmetric weakness, isolated cranial nerve disturbances were not reported in any of our
involvement and upper motor signs were excluded. patients. There were 04 (22%) deaths. The details of
A detailed history was taken from each patient and a the 4 deaths are shown in Table 1.
central nervous system (CNS) examination was
carried out. All patients received IVIG in a dose of Table 1: Details of the 4 deaths
2g per kg over 2 days. Nerve conduction velocity Patient Mode of Duration of
(NCV) study was done in all stable patients. As no. death hospital stay (days)
facilities for NCV study were not available in our 1 Sudden 07
hospital, patients were sent to the Vadodara Institute cardiac arrest
of Neurological Science for the same. Supportive 2 Sudden 06
care such as ventilation, intravenous (IV) fluid and cardiac arrest
antibiotics were provided as needed. CNS 3 Pulmonary 07
examination was carried out at the peak of the haemorrhage
disease and at the time of discharge. All data 4 Septic shock 12
obtained in the study were compared to other studies
done in adults due to lack of paediatric data. Hospital acquired complications in the 16 GBS
patients in our study are shown in Table 2.
Results
Eighteen paediatric GBS patients were enrolled for Table 2: Hospital acquired complications (n=16)
the study. Of them 11 (61%) were males and 07 Complication No. (%)
(39%) were females. Ages ranged from 2-12 years Urinary tract infection 02
with equal distribution among all age groups. Ventilator associated pneumonia 02
Antecedent events were observed in 07 (39%) which Pulmonary haemorrhage 01
included upper respiratory infection in 03, fever in
Bed sores 02
03 and diarrhoea in one. The latent period between
Left vocal cord palsy 01
illnesses ranged from 2 to 20 days. The clinical
profile is shown in Figure 1. Septicaemia 01
Exposure keratitis 01
Pneumothorax 01
Pulmonary tuberculosis 01
Hypoxic brain damage 01

Left vocal cord palsy was the result of prolonged

intubation. One patient who required hospitalisation
for 200 days developed pulmonary tuberculosis and
exposure keratitis. This same patient suffered
cardiac arrest twice which resulted in irreversible
hypoxic brain damage.

Various possible prognostic factors

• NCV study: Different types of NCV studies
and their outcome are shown in Table 2.

Table 2: Different types of NCV study and their outcome

Type of NCV study Number of Expired Discharged Mean Median
Patients duration of duration of
stay (days) stay (days)
Demyelination 06 02 04 10.3 9.5
AMAN + AMSAN 09 0 09 39.0 18.0
AMAN – Acute motor axonal neuropathy, AMSAN – Acute motor and sensory axonal neuropathy

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Guillain Barre Syndrome: A clinical observational… Sri Lanka Journal of Child Health, 2017; 46(3): 238-242

The most common type of NCV study was acute Table 3: Age and mortality
motor axonal neuropathy (AMAN) with 8 patients. Age No. of deaths (%)
Out of 4 patients who died 2 had demyelination as 2-5 years 0 (0)
NCV type. We could not do NCV studies in the other 6-8 years 02 (50)
two patients who died as they required mechanical 9-12 years 02 (50)
ventilation since admission. One patient had mixed Total 04 (100)
finding in NCV study which did not fit into any of
the classified forms. Recovery was prolonged in Table 4: Mean duration of hospital stay according
AMAN and AMSAN variety with both mean and to age group
median duration of stay being longer (Table 2). Age group Mean duration of stay
2-5 years 12.83 days
• Age: In our study mortality was more in the 6-8 years 17.67 days
higher age group as shown in Table 3. 9-12 years 55.17 days
• Duration of stay in hospital: This was more • Weakness at the time of admission: The
in the age group 9-12 years, as shown in association between weakness at the time
Table 4. of admission and outcome is shown in
Table 5.

Table 5: Association of weakness at the time of admission and outcome

Weakness at time of admission No. of patients No. expired (%) No. discharged (%)
Quadriparesis 12 04 (33.3) 08 (66.7)
Paraparesis 06 0 06 (100.0)

In our study all the patients who got admitted were quality of nursing care and long term intensive care,
given IVIG just after admissions. as patients are often bedridden and may require
prolonged ventilation. In our study the mortality rate
Discussion was 22% which was slightly less than the mortality
Studies by Rees et al, Yuan et al, and Rocha et al rate in the study by Farhoudi et al in Iran (22.9%)
reported a higher percentage in males which is in and much more than the mortality rates in studies
accordance with our study2,3,4. However, a study by done by Italian Guillain-Barré Syndrome Study
Farhoudi et al reported a higher percentage in Group (11%) and Ramírez-Zamora et al from Spain
females5. In our study, ages were uniformly (2.9%)5,6,9. Reported mortalities are lower in Italy
distributed within an age range of 2-12 years which and Spain which are developed countries with better
is not in accordance with studies by Rees et al, standards of medical and nursing care. Patients at
Italian Guillain-Barré Syndrome Study Group and our institute are mostly poor, illiterate, and ignorant
Van Koningsveld et al where the incidence of GBS and tend to consult a tertiary centre quite late.
was found to increase with the age2,6,7. In studies by Availability of IVIG and ventilator care can be a
Jacobs et al and Farhoudi et al, the percentage of limitation in an institute with a large patient load. It
patients with preceding illness was 70% in is often difficult in a general hospital to adhere to the
comparison to 39% in our study5,8. In the study by norms and recommendations regarding space
Farhoudi et al, quadriparesis was seen in 91% and criteria per patient and patient to nurse ratio. It is
paraparesis in 07% whereas in our study 67% had therefore common to see a higher rate of infections
quadriparesis and 33% had paraparesis5. Cranial and other complications in these patients. The
nerve involvement was found in 41.6% in the study proportion of patients who required ventilation in
by Farhoudi et al, 58% in the study by Taly et al and our study (44.4%) was almost double that in the
52% in the study by Sarkar et al compared to 27.8% study by Farhoudi et al in Iran (22.9%) which points
in our study5,10,11. Sensory system involvement has to late referral and more severe patient profile in our
been reported in 33% in the study by Farhoudi et al study5. The hospital acquired complications seen in
and 21% in the study by Taly et al but was not found our study (Table 2) are also with other chronic
in our study5,10. Bladder disturbances were reported disease requiring prolonged hospital stay.
in 9.1% in the study by Farhoudi et al but was not
found in our study5. Most of the death in our study occurred within a few
days of admission. All these patients were on
Outcome in a disease like GBS is significantly ventilator support. Most common mode of dying
influenced by early reporting of the patients, so that was sudden cardiac arrest which can be attributed to
IVIG can be administered before the onset of the autonomic disturbance. Tachycardia is common
respiratory paralysis and bulbar musculature but more serious autonomic nervous system
involvement. Furthermore, it also depends on the dysfunction may occur, including life-threatening

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Guillain Barre Syndrome: A clinical observational… Sri Lanka Journal of Child Health, 2017; 46(3): 238-242

arrhythmias and hypotension. Autonomic 2. Rees JH, Thompson RD, Smeeton NC,
disturbances are sudden and transient, so that Hughes RA. Epidemiological study of
managing and recording such disturbances without Guillain-Barré syndrome in south east
proper facilities is a challenge. England. Journal of Neurology,
Neurosurgery and Psychiatry 1998;
In a study by Hiraga et al12 the commonest NCV 64(1):74-7.
type was AMAN (45%), followed by acute https://doi.org/10.1136/jnnp.64.1.74
inflammatory demyelinating
polyradiculoneuropathy (AIDP) (34%) and 3. Yuan CL, Tsou HK, Wang YJ, Tsai CP.
unclassified (21%). Recovery was prolonged in Guillain-Barré syndrome: a retrospective,
AMAN type compared to AIDP but no significant hospital-based study. Zhonghua Yi Xue Za
difference in the final outcome of the patients was Zhi (Taipei) 2002; 65(11):540-7.
seen12. Italian Guillain-Barré Syndrome Study
Group 6 showed that evidence of axonopathy may be
4. Rocha MSBS, Carvalho AA, Lima UW.
independently associated with more severe disease
Epidemiologic features of Guillain-Barré
variety and less chances of recovery. Thus, some of
syndrome in. São Paulo, Brazil. Arq
the studies have shown that AMAN takes more time
Neuropsiquiatr 2004; 62:33-7.
to recover, but none of the studies has linked NCV
https://doi.org/10.1590/S0004282X20040
study type directly to the mortality in the patients of
00100006
GBS. In our study, the commonest NCV type was
PMid: 15122430
AMAN (50%) followed by demyelination (37.5%).
In our study 2 out of 6 patients (33.3%) with
5. Farhoudi M, Ayromlou H, Bazzazi AM,
demyelination died but there were no deaths among
Shadi FB, Golzari SEJ, Ghabili K, et al.
the other NCV types. Thus demyelination has some
Time frequency of Guillain-Barre
association with mortality but more studies are
Syndrome in Northwest of Iran. Life
needed to confirm this finding.
Science Journal 2013;10(1):223-5.
The poorer outcome of Guillain-Barre syndrome in
older patients has been reported by the Italian 6. Italian Guillain-Barré Syndrome Study
Guillain-Barré Syndrome Study Group. This could Group. The prognosis and main prognostic
be due to due to poor axonal outgrowth and indicators of Guillain-Barre syndrome: A
regeneration and less effective re-myelinisation as multicentre prospective study of 297
suggested by the Italian Guillain-Barré Syndrome patients. Brain 1996; 119:2053-61.
Study Group6. In our study there were no deaths in https://doi.org/10.1093/brain/119.6.2053
the 2-5 year age group, all deaths occurring in the 6-
12 year age group. Quadriparesis at the time of 7. Van Koningsveld R, van Doorn PA,
admission was associated with a 33.3% mortality Schmitz PI, Ang CW, van der Meché FG.
compared to paraparesis which was not associated Mild forms of Guillain-Barré syndrome in
with any mortality. The main limitation of our study an epidemiologic survey in The
was the mall sample size. Thus, all the findings need Netherlands. Neurology 2000; 54(3):620-5.
verification in a larger sample. https://doi.org/10.1212/WNL.54.3.620
PMid: 10680793
Conclusions
In the study carried out in a tertiary care centre in 8. Jacobs BC, Rothbarth PH, van der Meché
Gujarat, India, antecedent infection was seen in 38% FG, Herbrink P, Schmitz PI, de Klerk MA
of patients. There was a 22% mortality and et al. The spectrum of antecedent infections
demyelination NCV study was seen in 50% of the in Guillain-Barré syndrome: a case-control
expired patients. The prognosis was poorer in the study. Neurology 1998; 51(4):1110-5.
older age groups. Patients with quadriparesis had a https://doi.org/10.1212/WNL.51.4.1110
poorer prognosis than those with paraparesis. PMid: 9781538

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