Multiple Sclerosis and other Neurological Conditions
Lillian D. Sidky, BS
Medical Student
Tufts University School of Medicine
Boston, Massachusetts, United States
Lauren Topor, MD
Resident Physician
Department of Physical Medicine & Rehabilitation, University of Minnesota, Minneapolis, MN
Minneapolis, Minnesota, United States
Michael Kasprzak, DO
Physician
Department of Physical Medicine & Rehabilitation, University of Minnesota, Minneapolis, MN
Minneapolis, Minnesota, United States
Lillian Sidky
Tufts University School of Medicine
Boston, Massachusetts, United States
A 22-year-old previously healthy male was admitted to the acute rehabilitation unit (ARU) with Guillain-Barre Syndrome (GBS) diagnosed via cerebral spinal fluid analysis. Before ARU transfer, he completed a 5-day course of IVIG and steroids and was ambulating with a platform walker and minimum assistance, reporting improved bilateral strength. During his three-day ARU course, he functionally declined, developed symmetrical facial weakness, requiring maximum assistance and wheelchair mobility. He was diagnosed with treatment-related fluctuation of GBS and was transferred back to acute care for further treatment, receiving another 5-day course of IVIG. His symptoms worsened to include severe bulbar dysfunction, requiring seven rounds of plasmapheresis, which led to significant improvement. The patient was re-admitted to the ARU, where over four days he advanced to completely independent mobility and discharged home.
Discussions: Guillain-Barre Syndrome (GBS) is an acute polyneuropathy that generally presents with ascending muscular weakness and areflexia via inflammatory demyelination and/or axonal degeneration. The disease course involves neurologic progression for up to two weeks, plateauing for 2-4 weeks, then recovery. Most patients recover by four weeks. However, about 40% of patients do not improve within four weeks of treatment with plasmapheresis or IVIG and 10% actually have worsening of weakness following treatment. This worsening is referred to as treatment-related fluctuation (TRF) which has been found to occur at day 21 on average, but ranged between 10-60 days following treatment. Given this timeline, treatment-related fluctuation of GBS is important to consider in the acute inpatient rehabilitation unit.
Conclusions: Patients with GBS require close monitoring in acute rehabilitation, especially near the three-week mark, for early recognition of TRF. It is imperative to catch this early, as patients can have rapid worsening of weakness and/or respiratory status, as in this patient, which cannot be adequately managed in the rehab unit.
