Mild Guillain-Barre syndrome

Background: The unpredictability of the early course of Guillain-Barre synd rome (GBS) makes it difficult to determine which patients' conditions will: worsen under observation. Most large randomized treatment trials for GBS h ave used an inability to walk as the enrollment criterion. Consequently, li ttle is known about the treatment of those patients with milder degrees of affection. Objectives: To determine the approximate frequency of mild GBS with the per sistent ability to walk and to see if there were features that predicted th at the illness would remain mild. Setting: A registry of patients with GBS seen on the wards and in the neuro logy clinic from January 1, 1992, to May 1, 2000, in a 400-bed community te aching hospital. Patients: Twelve (4.7%) of 254 patients in our case series were able to wal k throughout their illness. Eight had been treated with plasmapheresis or i ntravenous immunoglobulin; the others were observed without treatment. Results: There was no age, sex, or seasonal preponderance in comparison wit h, large case series that included cases of all severities. Nine of 12 pati ents had a preceding respiratory tract infection, 10 had paresthesias, 7 ha d prominent pain, and 9 had ataxia. Seven of 10 patients who were examined had normal cerebrospinal fluid protein levels. It took 8 days, on average, to reach the maximal degree of weakness. One additional treated patient, ex cluded from our case series, had mild weakness for the first 3 weeks and su bsequently worsened with a relapsing course more typical of chronic inflamm atory demyelinating polyneuropathy. Eleven patients demonstrated proximal, intermediate, or distal conduction block, and only 3 had a mild degree of d enervation. There were no distinguishing clinical or electrophysiologic fea tures between treated and untreated patients with mild GBS and, except for the mild degree of affection and the absence of substantial electromyograph ic changes of axonal disruption, there were no important differences betwee n these mild cases as a group and patients who developed more severe GBS. Conclusions: Cases of mild GBS reach a clinical nadir in a similar time to those with more severe disease. Treatment may be unnecessary inpatients who are able to walk during the second week of illness, but observation until approximately the eighth day seems appropriate to be certain that the illne ss does not progress. In all likelihood there are mild cases of GBS that ne ver come to the attention of a neurologist.