Case Repot

7/28/2019 Case Repot

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Definition

• acquired disorder of the peripheral nerve, progressive, symmetrical,usually ascending weakness

• Described best as a polyradiculoneuropathy

• Guillain-Barré syndrome (GBS) is a rare autoimmune neurologicaldisease in which the body’s immune system produces antibodies

against its own nerves, resulting in damage to them.



Epidemiology 1 –3/100 000 population according to epidemiologicalstudies from Europe, USA, and Australia

male-to-female ratio of 1.5:1

incidence in children is lower, with estimatesbetween 0.4 and 1.3 cases per 100,000 per year

GBS can occur at any age but is rare in childrenunder the age of 2 years



Etiology

Post-infectious• immune-mediated disease targeting peripheral nerves

• virulence of C jejuni is thought to result from the presence of specific antigens in its capsule that are shared with nerves

• CMV infections present as upper respiratory tract infections,

pneumonias, and nonspecific flulike illnesses

Administration of certain vaccinations



Clinical manifestation

evolving areflexic motor paralysis withor without sensory disturbance

bulbar weakness with difficultyhandling secretions and maintaining an

airway

Autonomic involvement fluctuation inblood pressure, postural hypotension,

and cardiac dysraythmias



Subtypes of GBS • commonest type of Guillain-Barré syndrome

• lymphocytic infiltration of the peripheral nerves and macrophage mediatedsegmental demyelination

Acute inflammatorydemyelinating

polyradiculoneuropathy

• Wallerian-like degeneration of motor axons exclusively

• rapidly progressive weakness, often with respiratory failure and usually goodrecovery.

• muscle action potential amplitudes are reduced

Acute motor axonalneuropathy

• axonal degeneration with no demyelination or inflammationAcute motor sensoryaxonal neuropathy

• ataxia, areflexia, and ophthalmoplegia

• Anti-GQ1b antibodies were found oculomotor nerve contained the highestconcentration of GQ1b gangliosides conduction block is the most likelymechanism of ophthalmoplegia.

Miller fisher syndrome



Pathogenesis



classic pathological findings in acute

inflammatory

IgG and activated complement bind tothe axolemma of motor fibers at thenodes of Ranvier, followed by formation

of the membrane-attack complex.

nodal lengthening is followed by axonal

degeneration of motor fibers withneither lymphocytic inflammation nordemyelination



Follow up

J 10th 2013



January, 10th 2013

S Weakness of both upper and lower extremities (+), fever (-)

o CNS Stable, sens: compos mentis,

Eye: isochoric pupil, light reflex (+/+), 2 mm

Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warmacral

Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T- piece O2 8L/I, SpO2 92-94%

Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and providential retgen

Gastrointestinal Stable, soepel, normoperistaltic, clear NGT

Hematology Unstable, Hb/Ht/L/Tr: 10,4/31,8/14.950/213000

Musculoskeletal Stable, edema (-)

physiology reflex: APR/KPR: +/+

pathology reflex: (-)

muscle strength: 22222/222222

22222/22222

A Respiratory failure ec Guillain-Barré Syndrome with unstable respiratory system, infection and musculoskeletal

system

P Management:

- T-piece attached O2 8L/I SpO2 92-94%

- IVFD D5% NaCl 0,9%

- Inj Ranitidine 25 mg/12 hr/IV

- Inj Meropenem 800 mg/12 hr/ IV (day 15th)

- Inj Farmadol 220 mg/ IV (if needed)

- Inj dexamethasone 11 mg/8hr/IV

- Ambroxol syr 3 x 5cc

- Zamel syr 1 x cth

- Nebule NaCl 0,9% 2,5cc/8hr

- Diet 70 cc/kgBW/day 190 cc/3hr

- CVP/6hr

- Chest physiotherapy

Diagnostic Planning: - Lumbal puncture

- Check albumin, T3, T4, TSH



Blood Gas Analysis Result Unit Referral

pH 7.459 7.35-7.45

pCO2 32.0 mmHg 38-42

pO2 134.7 mmHg 85-100

Bicarbonat 22.2 mmol/L 22-26

Total CO2 23.2 mmol/L 19-25

Base Excess -1.3 mmol/L (-2) - (+2)

O2 Saturation 99.1 % 95 – 100



January, 11th 2013




Cardiovascular Stable, HR: 118 bpm, regular, murmur (-), CRT < 3’’, MAP: 93 mmHg, adequate p/v, warm

acral

Respiratory Unstable, thorax: simetris fusiformis, epigastrial retraction (-), ETT attached, RR: 22x/i, T-

piece O2 8L/I, SpO2 92-94% Infection Ustable, fever (-), temp: 37,1C, leukocyte: 14.950/mm3 culture bacillus aureus (+) and

providential retgen







22222/22222A Respiratory failure ec Guillain-Barré Syndrome with unstable respiratory system, infection and musculoskeletal

system

P Management:


- IVFD D5% NaCl 0,9% + Ca. glukonas 10 mEq 20 gtt/I micro






- Zamel syr 1 x cth



- CVP/6hr




Lumbar puncture Result Unit Referral

Color Serous Serous

LDH 31 U/L < 200

Total protein 36.00 mg/dL < 45

Total leucocyte 0.001 10³/uL < 3

Total erythrocyte 0.000 10³/uL

Glucose 96 mg/dL 40 – 76

pH 7.5 7 – 8

MN cell 100.0 %

PMN cell 0.0 %

Result immunoserology

Total T3: 0,60 ng/ml (0,8-2)

Total T4: 8,63 g/dl (5-14)

TSH: 0,478 IU/ml (0,27-4,2)



January, 12th 2013 and January, 13th 2013





acral



providential retgen








system

P Management:








- Zamel syr 1 x cth



- CVP/6hr




January, 14th 2013





acral



providential retgen








system

P Management:


- Inj ceftazidine 500 mg/8hr/IV (day 1st)





Diagnostic Planning:

Check electrolite



January, 15th 2013





acral



providential retgen







22222/22222A Guillain-Barré Syndrome

P Management:







Result of electrolyte:

Ca: 7,7 mg/dl

Na: 132 mEq/l

K: 3,6 mEq/l



January, 16th 2013 and January, 17th 2013





acral



providential retgen








P Management:





- Nebule NaCl 0,9% 2,5cc/8hr - Diet 70 cc/kgBW/day 190 cc/3hr



January, 18th 2013 - January, 20 th 2013





acral



providential retgen








P Management:








January, 21st 2013 - January, 22nd 2013





acral



providential retgen








P Management:


- Inj ceftazidine 500 mg/8hr/IV (day 9th)



- Diet 70 cc/kgBW/day 190 cc/3hr - Physiotheraphy

Diagnostic Planning:

Check blood routine, electrolyte, LFT, RFT, glucose ad random



Complete Blood Count Result Unit Referral

Hb 10.40 gr% 11.3 – 14.1

WBC 8.33 x 103/mm³ 4.5 – 13.5

RBC 3.97 x 106/mm³ 4.40 – 4.48

Hematocrite 31.90 % 37 – 41

PLT 387 x 10³/mm³ 150 – 450

MCV 80.40 fL 81 – 95

MCH 26.20 Pg 25 – 29MCHC 32.60 g% 29 – 31

RDW 17.00 % 11.6 – 14.8

MPV 8.80 fL 7.0 – 10.2

PCT 0.34

PDW 9.0

Neutrophil 44.70 % 37 – 80

Lymphocyte 39.50 % 20 – 40

Monocyte 13.90 % 2 – 8

Eosinophil 1.3 % 1 – 6Basophil 0.6 % 0 – 1

Liver Result Unit Referral

Total bilirubin 0.34 mg/dL < 1

Direct bilirubin 0.09 mg/dL 0 – 0.2

AST 26 U/L < 38

ALT 18 U/L < 41

Kidney Result Unit Refferal

Ureum 13.10 mg/dL < 50

Creatinine 0.24 mg/dL 0.32 – 0.59

Uric acid 2.9 mg/dL < 7.0

Electrolyte Result Unit Referral

Sodium 133 mEq/L 135-155

Calcium 9.2 mg/dL 9.2 – 11.0

Pottasium 4.1 mEq/L 3.5-5.5

Phosphor 6.2 mEq/L 3.4 – 6.2

Chloride 113 mEq/L 96-106

Magnesium 2.35 mEq/L 1.4 – 1.9



January, 23rd 2013 - January, 25th 2013





acral



providential retgen








P Management:


- Inj ceftazidine 500 mg/8hr/IV (day 9th)



- Diet 70 cc/kgBW/day 190 cc/3hr - Physiotheraphy



• Patient was discharged from hospital on25th January 2013 because his condition

of stability was improved. NGT waschanged. Family patient has beeneducated regarding to the method of using the NGT at home. Patient has beentold to be controlled at the policlinic of

neurology pediatric and get thephysiotherapy once per week.

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