Case Study - How back pain revealed rare syndrome

Acute-onset pain and progressive muscle weakness in an elderly lady initially puzzled Dr Honor Merriman.

Rose, an independent and public-spirited 74-year-old, presented with acute onset of lumbar back pain.

The pain was so acute that a neighbour had taken her to the local A&E department two days previously, where she had been examined and had blood tests. She had also had an MRI scan. No abnormality was found and she was discharged.

Pain relief seemed to be the obvious thing she needed. While discussing how she would manage with her current limited mobility it was noticed that her right lower face was weak, and no reflexes could be elicited on either of her legs.

She was keen to stay at home but as she was not able to take more than one step at a time, and could not be cared for by any of her elderly neighbours, she was re-admitted.

Two weeks later she was discharged with a diagnosis of Guillain-Barre syndrome. The diagnosis had been made on the history of progressive muscular weakness and through nerve conduction studies which showed a sensory motor demyelinating neuropathy.

Rare syndrome

Although uncommon, Guillain-Barre syndrome occurs in two cases in every 100,000 of the population. In a practice of 13,000 that is one case roughly every four years.

Severe pain occurs in 90 per cent of cases. Cranial nerve palsies are also common.

The speed of recovery is very variable and can be split into three stages: nadir (increasing severity of symptoms) with a mean lasting time of 12 days; improvement with a mean lasting time of 28 days; and recovery with a mean lasting time of 28 days.

Initially there were three options for treatment, but because Rose started improving during admission she was given physiotherapy.

More severe cases are considered for plasmapheresis or IV immunoglobulins.

Combining IV steroids with IV immunoglobulins is used in a few cases.

Rose made a very slow recovery at home. She still has pain, but is now able to walk. The recovery is not as smooth and progressive as expected; some days she experiences tingling up to waist level. In her case, recovery is taking several months although the nadir was reached in a few days.

- Dr Merriman is a GP in Oxford

KEY POINTS

- Guillain-Barre syndrome occurs in two cases in every 100,000 of the population; in a practice of 13,000 that is one case approximately every four years.

- Severe pain occurs in 90 per cent of cases.

- Accompanying cranial nerve palsies are common.

- The onset and recovery period can be divided into three phases: nadir (12 days), improvement (28 days), and recovery (28 days).

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