Review Question - QID 221270

Guillain-Barre Syndrome Studies Lumbar puncture QID: 221270 (M2.OMB.4885)

QID 221270 (Type "221270" in App Search)

A 13-year-old girl is brought to urgent care by her mother after she began complaining of increasing weakness for the last 8 hours. She recently traveled with her family on a cruise and has been experiencing diarrhea for 3 days. She has been managing it with rest and hydration but then began to feel very weak while walking to the movies with her friends. Over the last day, the weakness has become much worse and is now affecting her arms as well. She has no other significant medical history and takes no medications. Her temperature is 98.6°F (37.0°C), blood pressure is 110/70 mmHg, pulse is 90/min, and respirations are 12/min. Physical exam reveals 1/5 strength in her lower extremities, 3/5 strength in her upper extremities, and decreased sensation to light touch and pinprick diffusely. She is also found to have absent patellar and ankle reflexes. A lumbar puncture in this patient would most likely show which of the following sets of findings seen in Figure A?

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This patient with a recent history of gastroenteritis now presents with progressive ascending weakness and sensory loss, as well as diminished reflexes, consistent with Guillain-Barré syndrome. This disease would present with an isolated increase in cerebrospinal fluid protein levels without an increase in white blood cell count or glucose.

Guillain-Barré syndrome is an immune-mediated polyneuropathy that is due to cross-reactivity between pathogenic antigens and host myelin. A classic association is with a previous diarrheal infection caused by Campylobacter jejuni. Spirometry allows for the determination of whether the patient's respiratory function is adequate and can guide whether early intubation is necessary. Nerve conduction studies will reveal slowed conduction velocity and reduced amplitude in compound muscle action potentials. Lumbar puncture is able to support the diagnosis and will classically show albuminocytologic dissociation with elevated protein but a normal white blood cell count. Treatment includes supportive management and immunomodulatory therapy with intravenous immune globulin or plasma exchange.

Rath et al. discuss different methods of quantifying the classic finding of albuminocytologic dissociation in patients with Guillain-Barré syndrome. They find that a longer duration from clinical onset to lumbar puncture was associated with a higher diagnostic yield. They recommend using the CSF/serum albumin quotient.

Figure A is a table showing the results of CSF testing after a lumbar puncture.

Incorrect Answers:
Answer 1: Normal protein, normal glucose, and normal white cells in the CSF would be seen in peripheral causes of weakness such as myasthenia gravis. This disease would present with weakness greater after muscle use or at the end of the day. Weakness improves with rest and pyridostigmine administration.

Answer 2: Normal protein, normal glucose, and elevated white cell count in the CSF would be seen in viral meningitis. This disease would present with headache and neck stiffness with photophobia. Patients do not present as ill as those with bacterial meningitis.

Answer 4: Increased protein, decreased glucose, and elevated white cell count in the CSF would be seen in bacterial meningitis. This disease would present with rapid onset of neurologic deficits, headache, and fever.

Answer 5: Increased protein, normal glucose, and elevated white cell count in the CSF would be seen in fungal meningitis. This disease typically presents in immunocompromised patients with neurologic deficits.

Bullet Summary:
Guillain-Barré syndrome presents with ascending paralysis and albuminocytologic dissociation in the cerebrospinal fluid.