What are the symptoms of Guillain-Barré Syndrome (GBS)?

Symptoms of Guillain-Barré Syndrome

Guillain-Barré syndrome presents with rapidly progressive bilateral ascending weakness starting in the legs and moving to the arms and cranial muscles, accompanied by decreased or absent reflexes, with most patients reaching maximum disability within 2 weeks of symptom onset. 1

Core Motor and Sensory Symptoms

• Bilateral ascending weakness is the hallmark feature, typically beginning in the legs and progressing upward to the arms and cranial muscles over days to 2 weeks 1, 2
• Distal paresthesias or sensory loss often precede or accompany the weakness, with patients reporting tingling or numbness that starts distally and ascends 1
• Decreased or absent deep tendon reflexes occur in most patients at presentation and nearly all patients at their worst point (nadir), typically beginning in the lower limbs 1, 2
• Facial weakness can occur, with bilateral facial palsy being a particularly characteristic finding 2

Respiratory and Bulbar Symptoms

• Respiratory insufficiency develops in approximately 20% of patients and can occur rapidly without preceding dyspnea symptoms, making this a critical early complication to monitor 1, 3
• Swallowing and coughing difficulties indicate bulbar involvement and create aspiration risk 4, 2
• Patients may have difficulty breathing that progresses to requiring mechanical ventilation, often without obvious warning signs 4

Autonomic Dysfunction

• Blood pressure and heart rate instability are common manifestations of autonomic nervous system involvement 1, 2
• Pupillary dysfunction can occur as part of the autonomic disturbance 1
• Bowel and bladder dysfunction may develop, though marked bladder dysfunction at onset should prompt reconsideration of the diagnosis 2

Pain Symptoms

• Pain is frequently reported and can be an early symptom, affecting approximately two-thirds of patients 1, 2
• Pain may be muscular, radicular, or neuropathic in character and can sometimes precede weakness, making early diagnosis challenging 1, 2
• Back and limb pain are particularly common presentations 2

Cranial Nerve Involvement

• Ophthalmoplegia (eye movement weakness) occurs in Miller Fisher syndrome variant, characterized by the triad of ophthalmoplegia, ataxia, and areflexia 2
• Facial palsy can be bilateral and requires assessment for corneal reflex to prevent corneal ulceration 2

Temporal Pattern and Preceding Events

• Acute or subacute onset with symptoms developing over days, with maximum disability typically reached within 2 weeks (though diagnostic criteria allow up to 4 weeks) 1, 3
• Recent infection history within the preceding 6 weeks is reported by approximately two-thirds of patients, commonly gastrointestinal or respiratory infections 1, 2
• Nadir reached in less than 24 hours should cast doubt on the diagnosis, as this is atypically rapid even for GBS 3

Psychological and Cognitive Symptoms

• Anxiety, depression, and hallucinations are frequent complications that should be specifically assessed, especially in patients with limited communication abilities 4, 2
• Consciousness, vision, and hearing remain intact even in patients with complete paralysis, which is an important distinguishing feature 4, 2

Clinical Variants

• Classic sensorimotor form (70% in Europe/Americas, 30-40% in Asia) presents with both motor and sensory symptoms 2
• Pure motor variant (5-70% of cases) presents with motor weakness without sensory signs 2
• Miller Fisher syndrome (5-25% of cases) presents distinctively with ophthalmoplegia, ataxia, and areflexia 2

Important Clinical Pitfalls

• Marked persistent asymmetry of weakness should prompt reconsideration of the diagnosis 2
• Marked cerebrospinal fluid pleocytosis (elevated white blood cells) is atypical and should raise concern for alternative diagnoses 2
• Progression continuing beyond 8 weeks from onset suggests acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) rather than GBS, occurring in approximately 5% of initially diagnosed GBS patients 5