What is the treatment for Guillain-Barré Syndrome (GBS) following a Respiratory Syncytial Virus (RSV) infection?

Treatment of Guillain-Barré Syndrome Following RSV Infection

Intravenous immunoglobulin (IVIg) at a dose of 0.4 g/kg body weight daily for 5 days is the first-line treatment for Guillain-Barré Syndrome following RSV infection, due to its effectiveness, easier administration, and better completion rates compared to plasma exchange. 1

First-Line Treatment Options

• IVIg (0.4 g/kg body weight daily for 5 days) is the preferred first-line therapy due to better tolerability and fewer complications compared to plasma exchange 2, 1
• Treatment should be initiated as early as possible in the disease course to maximize effectiveness 1
• Plasma exchange (200-250 ml plasma/kg body weight in five sessions over 2 weeks) is an effective alternative when IVIg is contraindicated, not tolerated, or unavailable 2, 1
• Corticosteroids alone are NOT recommended for GBS treatment as they have shown no significant benefit and may even have negative effects on outcomes 2, 1

Respiratory Monitoring and Support

• Regular assessment of respiratory function is essential using the following parameters:
  • Vital capacity (risk if <20 ml/kg)
  • Maximum inspiratory pressure (risk if <30 cmH₂O)
  • Maximum expiratory pressure (risk if <40 cmH₂O) 2
• Single breath count and use of accessory respiratory muscles should be monitored 2
• Swallowing and coughing difficulties should be assessed to prevent aspiration 2
• Up to 30% of patients develop respiratory failure requiring mechanical ventilation 3
• Consider mechanical ventilation when vital capacity falls below 12-15 ml/kg or arterial PO2 below 70 mm Hg 4

Management of Disease Progression

• About 40% of patients do not show improvement in the first 4 weeks following treatment, which doesn't necessarily indicate treatment ineffectiveness 2, 1
• Treatment-related fluctuations (TRFs) occur in 6-10% of patients within 2 months of initial improvement 2, 1
• For patients with TRFs, repeating the full course of IVIg or switching to plasma exchange is common practice 2, 1
• In approximately 5% of cases initially diagnosed as GBS, the diagnosis may change to acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) if repeated relapses occur 2, 5

Supportive Care and Complication Management

• Multidisciplinary supportive care should include pain management, as pain is common in GBS patients 2
• Prevention of pressure ulcers, hospital-acquired infections, and deep vein thrombosis is essential 2
• Management of autonomic dysfunction through monitoring of heart rate, blood pressure, and bowel/bladder function is necessary 2
• Psychological support for anxiety, depression, and hallucinations is crucial 2
• Patients should be monitored for cardiovascular complications, as up to two-thirds of deaths in GBS occur during the recovery phase due to cardiovascular and respiratory dysfunction 2

Rehabilitation Planning

• A rehabilitation program with a rehabilitation specialist, physiotherapist, and occupational therapist is crucial for recovery 6
• Exercise programs should include range-of-motion exercises, stationary cycling, walking, and strength training to improve physical fitness and independence in activities of daily living 6
• The intensity of exercise must be closely monitored as overwork can cause fatigue 6
• Management strategies for chronic pain include encouraging mobilization and administering drugs for neuropathic or nociceptive pain 6

Prognosis

• About 80% of patients regain walking ability at 6 months after disease onset 1
• Mortality occurs in 3-10% of cases, most commonly due to cardiovascular and respiratory complications 1
• Risk factors for mortality include advanced age and severe disease at onset 1
• Long-term residual complaints can include neuropathic pain, weakness, and fatigue, but recovery may still occur >5 years after disease onset 6

Special Considerations for RSV-Associated GBS

• For patients with GBS following RSV infection, consider palivizumab prophylaxis during RSV season if still in the acute phase of treatment 6
• Pneumocystis pneumonia (PCP) prophylaxis with trimethoprim/sulfamethoxazole (5 mg/kg/d trimethoprim by mouth 3 times per week) should be considered 6
• Early signs of infection should be promptly investigated and antimicrobial regimens initiated early and for prolonged periods 6