Guillain-Barré Syndrome Following Campylobacter Gastroenteritis
This 21-year-old patient has Guillain-Barré syndrome (GBS) triggered by Campylobacter gastroenteritis, and requires immediate hospitalization with intravenous immunoglobulin (IVIg) 0.4 g/kg daily for 5 days or plasma exchange.
Diagnosis
The clinical triad of diarrhea with fever followed by ascending paralysis is pathognomonic for post-infectious GBS, most commonly triggered by Campylobacter jejuni infection 1, 2.
Key Diagnostic Features
- Preceding infection: Diarrhea and fever occurring 1-3 weeks before neurologic symptoms strongly suggests Campylobacter as the trigger 1, 2
- Ascending paralysis pattern: Progressive weakness starting in lower extremities and moving upward is the hallmark presentation of GBS 3, 4
- Campylobacter-GBS association: This is the strongest documented infectious trigger for GBS, with 1 in 1,058 Campylobacter infections resulting in GBS 2
Confirmatory Testing
- CSF analysis: Look for cytoalbuminologic dissociation (elevated protein with normal cell count), though this may not appear until after the first week 3, 5
- Electrodiagnostic testing: Nerve conduction studies and EMG should be performed to support the diagnosis and classify the GBS subtype 5
- Stool culture: Test for Campylobacter jejuni, Salmonella, Shigella, and other enteric pathogens 1
- Anti-ganglioside antibodies: Testing has limited value in typical motor-sensory GBS but may be considered 5
Immediate Management
Hospitalization and Monitoring
- Admit immediately to a monitored setting with capability for mechanical ventilation 4, 5
- Assess respiratory function: Monitor vital capacity, negative inspiratory force, and oxygen saturation closely as respiratory failure is a life-threatening complication 3, 4
- Use mEGRIS score: Apply the modified Erasmus GBS Respiratory Insufficiency Score to assess risk of requiring artificial ventilation 5
Immunotherapy (Choose One)
The Task Force recommends either of these equally effective options 5:
Intravenous immunoglobulin (IVIg): 0.4 g/kg daily for 5 consecutive days if the patient is within 2 weeks of weakness onset and unable to walk unaided 5
Plasma exchange (PE): 12-15 liters over 4-5 exchanges during 1-2 weeks if within 4 weeks of weakness onset and unable to walk unaided 5
Critical caveat: Do NOT use PE followed immediately by IVIg, as combination therapy offers no additional benefit 5.
Antibiotics for the Gastroenteritis
Avoid antibiotics for the Campylobacter infection at this stage 1. The neurologic syndrome has already been triggered, and antibiotics do not alter the course of established GBS 5. Additionally, if STEC (Shiga toxin-producing E. coli) is still in the differential, antibiotics could worsen outcomes 1.
Monitoring for Complications
Respiratory Failure
- Most critical complication: Up to 30% of GBS patients require mechanical ventilation 4
- Monitor: Vital capacity, negative inspiratory force, ability to cough, and signs of respiratory distress 4, 5
- Intubate early if vital capacity falls below 15-20 mL/kg or patient shows signs of respiratory compromise 4
Autonomic Dysfunction
- Cardiac monitoring: Watch for arrhythmias, blood pressure fluctuations, and bradycardia 4, 5
- Bladder dysfunction: May require catheterization 4
Pain Management
- First-line agents: Gabapentinoids, tricyclic antidepressants, or carbamazepine for neuropathic pain 5
- Avoid NSAIDs alone: Neuropathic pain in GBS typically requires specific neuropathic pain medications 4
Thromboembolic Prophylaxis
- Initiate DVT prophylaxis: Use subcutaneous heparin or low-molecular-weight heparin given immobility 4
Prognosis Assessment
- Use mEGOS score: Apply the modified Erasmus GBS Outcome Score to predict functional outcome at 6 months 5
- Campylobacter-associated GBS: Neurologic symptoms are typically more severe and more likely to be irreversible compared to other triggers 2
- Recovery timeline: Most patients begin improving within 2-4 weeks of treatment initiation, but full recovery may take months 4, 5
Critical Pitfalls to Avoid
- Delaying treatment: Early initiation of IVIg or PE is essential to prevent life-threatening complications and improve outcomes 3, 4, 5
- Misdiagnosis as conversion disorder: Psychiatric history or atypical presentation should not delay consideration of GBS 3
- Giving a second course of IVIg: Do not administer a second IVIg course in patients with poor prognosis, as evidence does not support benefit 5
- Using corticosteroids: Oral corticosteroids are not recommended, and IV corticosteroids are weakly recommended against 5
- Continuing progression beyond 8 weeks: Consider changing diagnosis to acute-onset CIDP (A-CIDP) if weakness continues progressing after 8 weeks, which occurs in approximately 5% of cases 5