Can Guillain-Barré Syndrome (GBS) present with bilateral ascending sensory deficits?

Guillain-Barré Syndrome and Bilateral Ascending Sensory Deficits

Yes, Guillain-Barré Syndrome (GBS) classically presents with bilateral ascending sensory deficits, typically beginning with distal paresthesias or sensory loss that is accompanied or followed by weakness starting in the legs and progressing upward. 1, 2

Classic Clinical Presentation of GBS

• The classic sensorimotor form of GBS presents with distal paresthesias or sensory loss, accompanied or followed by weakness that starts in the legs and progresses to the arms and cranial muscles 1
• Sensory symptoms are bilateral, though they can sometimes be asymmetrical 1
• The sensory deficits typically have an ascending pattern, beginning in the distal extremities and moving proximally 1, 2
• Decreased or absent reflexes are found in most patients at presentation and in almost all patients at nadir 1
• Pain is frequently reported and can be muscular, radicular, or neuropathic in nature 1, 2
• Disease onset is acute or subacute, with patients typically reaching maximum disability within 2 weeks 1

Sensory Involvement in GBS Variants

• While the classic form is sensorimotor, there are several variants of GBS with different patterns of sensory involvement 1:
  • Pure motor variant (5-70% of cases): Motor weakness without sensory signs 1
  • Pure sensory variant (<1% of cases): Acute or subacute sensory neuropathy without motor deficits 1, 3
  • Miller Fisher syndrome (5-25% of cases): Characterized by ophthalmoplegia, ataxia, and areflexia 1

Diagnostic Considerations

• Sensory symptoms in GBS are always bilateral, though they can be asymmetrical or predominantly proximal or distal 1
• The presence of unilateral sensory symptoms should raise suspicion for alternative diagnoses 1
• Sensory deficits may precede motor weakness in some cases, making early recognition challenging 4
• In rare cases, pure sensory GBS can occur, presenting with objective sensory loss and diminished reflexes without muscle weakness 3

Clinical Pitfalls and Caveats

• Atypical presentations of GBS can lead to diagnostic delays:
  • Sensory symptoms may sometimes be overshadowed by pain, which is reported in many patients 1
  • Cranial nerve involvement can sometimes be the initial presentation, as seen in cases with vision deficits or hearing loss 5, 6
  • Autonomic dysfunction, including gastrointestinal symptoms like paralytic ileus, can occasionally precede the typical sensory and motor symptoms 7
• In young children (<6 years), GBS can present with nonspecific features such as poorly localized pain, refusal to bear weight, irritability, or unsteady gait 1
• Alternative diagnoses should be considered if maximum disability is reached within 24 hours or after 4 weeks from symptom onset 1

Diagnostic Confirmation

• Cerebrospinal fluid examination typically shows albumino-cytological dissociation (elevated protein with normal cell count), though protein levels may be normal in 30-50% of patients in the first week 1, 2
• Electrodiagnostic studies can confirm demyelinating neuropathy, even in cases with predominantly sensory symptoms 3
• The presence of antecedent infection (reported in about two-thirds of patients) in the 6 weeks preceding symptom onset supports the diagnosis 2