206 - Hidden in Plain Sight: Guillain-Barré Fluctuations Masked by Post-Surgical Sequelae

A 34-year-old female with a history of gastric bypass, medullary thyroid carcinoma status post thyroidectomy, and recently induced delivery presented for rehabilitation following Miller-Fisher variant of Guillain-Barre Syndrome (GBS) treated with intravenous immunoglobulin (IVIG). Initially making functional improvements, she later developed progressive fatigue, hypotension, and subtle upper extremity weakness within 2 weeks. Pre-existing early satiety from gastric bypass contributed to poor oral intake and dehydration, complicating interpretation of her fatigue and autonomic symptoms. Residual vocal cord paralysis and dysphagia from remote thyroidectomy further clouded assessment of bulbar involvement.

Discussions:

Post IVIG, GBS typically follows a monophasic course of improvement. Treatment related fluctuations (TRFs) are rare but potentially fatal if not diagnosed in a timely manner. With pre-existing post-surgical complications that contribute to autonomic instability and mimic bulbar signs, the clinical picture with initially subtle regressions during therapy was confounded. In the acute hospital, negative inspiratory force (NIF) and pulmonary function testing are used serially to detect subtle decline in patients with GBS. Since these tools are oftentimes unavailable in community rehabilitation settings, muscle strength grading sum scores provide a practical tool for monitoring progress and guiding escalation of care.

Conclusions:

Newly recognized overt bilateral upper extremity weakness and poor inspiratory effort prompted an acute care transfer. The patient received plasma exchange in the acute setting and later underwent a second phase of rehabilitation with strength improvements. This case underscores the difficulty of distinguishing true TRFs from post-surgical sequelae mimickers in a resource limited setting without advanced pulmonary testing. Attention to early respiratory assessments in the acute setting prior to rehab admission and objective bedside measures such as serial muscle strength grading built into admissions protocol can raise vigilance to better clinically detect TRFs and safeguard recovery in patients with GBS.