Compare and contrast Guillian-Barré syndrome (GBS), and acute transverse myelitis (ATM) in terms of the relevant history, the clinical features, and the relevant investigation findings.
Guillian-Barré |
Acute Transverse Myelitis |
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Relevant History |
Antecedent respiratory or diarrhoeal illness Campylobacter Jejuni Viral – EBV, HSV Mycoplasma Vaccination |
Antecedent respiratory, gastrointestinal, or systemic illness in 30-60%, can occur as part of the spectrum of multiple sclerosis, may be seen in patients with acute disseminated encephalomyelitis, other CNS infections or associated with a systemic autoimmune disease |
Motor Weakness |
Ascending, symmetrical motor weakness Parasthesia/pain Hypo/areflexia |
Pyramidal weakness below level of spinal cord lesion, bilateral signs |
Cranial Nerve Palsy |
Common Uni-/bilateral facial Bulbar |
Rare, may be associated with optic neuritis if part of MS spectrum |
Dysautonomia |
Yes |
May be present |
Sensory Deficit |
Absent or Mild, distal |
Clearly defined sensory level all modalities (spinothalamic and posterior columns) on the trunk at level of involvement |
CSF |
Elevated protein. No pleocytosis. |
Abnormal in 50%, moderate lymphocytosis (typically <100/mm3) and an elevated protein. Glucose levels are normal. Oligoclonal bands are usually not present in isolated TM, and when present suggest a higher risk of subsequent MS |
Neurophysiology |
Abnormal spontaneous activity |
Decreased/ unrecordable motor evoke potentials to lower limbs especially on |
Normal MUPs initially. Reduced recruitment. |
lumbar stimulation and evidence of denervation in leg muscles |
|
MRI |
Not diagnostic |
Gadolinium-enhancing signal abnormality (extending over one or more cord segments. Cord oedema at the level. |
This is another question in a long series of neurology questions asking the trainees to compare Guillain-Barre with other spinal weakness syndromes. The official college answer to this SAQ was actually quite extensive, and likely represents an earnest effort from the examiners. It would be difficult to improve on such an answer. One can merely rearrange the categories and add some irrelevant tidbits here and there. The product appears below.
Guillian-Barré | Acute Transverse Myelitis |
Pathophysiology | |
Acute inflammatory demyelinating peripheral neuropathy associated with infection such as:
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Autoimmune inflammation of the spinal cord; may be idiopathic or associated with other illnesses:
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Typical features of history | |
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Power | |
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Tone | |
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Reflexes | |
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Cranial nerves | |
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Autonomic features | |
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Sensory findings | |
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CSF features | |
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Nerve conduction studies | |
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Electromyography | |
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MRI | |
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Chapter 57 (pp. 617) Neuromuscular diseases in intensive care by George Skowronski and Manoj K Saxena
van den Berg, Bianca, et al. "Guillain-Barre syndrome: pathogenesis, diagnosis, treatment and prognosis." Nature Reviews Neurology 10.8 (2014): 469-482.
Yuki, Nobuhiro, and Hans-Peter Hartung. "Guillain–Barré syndrome." New England Journal of Medicine 366.24 (2012): 2294-2304.
Raphael, J. C., et al. "Plasma exchange for Guillain-Barré syndrome." Cochrane Database Syst Rev 2.2 (2002).
Venkata Umakant, K., B. Seshulakshmi, and B. Srinivasa Rao. "Miller Fisher Syndrome–An Atypical Clinical Presentation." Intern Med 3.119 (2013): 2.
Berlit, Peter, and Josef Rakicky. "The Miller Fisher syndrome: review of the literature." Journal of Neuro-Ophthalmology 12.1 (1992): 57-63.
Odaka, M., N. Yuki, and K. Hirata. "Anti-GQ1b IgG antibody syndrome: clinical and immunological range." Journal of Neurology, Neurosurgery & Psychiatry70.1 (2001): 50-55.
Alkan, Ozlem, et al. "Spinal MRI findings of guillain-barre syndrome." Journal of radiology case reports 3.3 (2009): 25.
Cabrera Serrano, M., and A. A. Rabinstein. "Usefulness of pulmonary function tests and blood gases in acute neuromuscular respiratory failure." European Journal of Neurology 19.3 (2012): 452-456.
Farrero, Eva, et al. "Guidelines for the Management of Respiratory Complications in Patients With Neuromuscular Disease." Archivos de Bronconeumología (English Edition) 49.7 (2013): 306-313.
Hughes, Richard AC, et al. "Supportive care for patients with Guillain-Barré syndrome." Archives of neurology 62.8 (2005): 1194-1198.
Massam, M., and R. S. Jones. "Ventilatory failure in the Guillain-Barré syndrome." Thorax 35.7 (1980): 557-558.
González-Suárez, Inés, et al. "Guillain-Barré Syndrome: Natural history and prognostic factors: a retrospective review of 106 cases." BMC neurology 13.1 (2013): 95.
Dhand, Upinder K. "Clinical approach to the weak patient in the intensive care unit." Respiratory care 51.9 (2006): 1024-1041.
Sanders, Donald B., and Janice M. Massey. "Clinical features of myasthenia gravis." Handbook of clinical neurology 91 (2008): 229-252.
Bird, Shawn J. "Clinical manifestations of myasthenia gravis." Up-to-date 16.1 (2008): 1-8.
Gronseth, Gary S., and Richard J. Barohn. "Practice parameter: Thymectomy for autoimmune myasthenia gravis (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology." Neurology 55.1 (2000): 7-15.
Gajdos, Philippe, Sylvie Chevret, and Klaus V. Toyka. "Plasma exchange for generalised myasthenia gravis." The Cochrane Library (2002).
Gajdos, Philippe, et al. "Treatment of myasthenia gravis exacerbation with intravenous immunoglobulin: a randomized double-blind clinical trial." Archives of neurology 62.11 (2005): 1689-1693.
Jacob, Anu, and Brian G. Weinshenker. "An approach to the diagnosis of acute transverse myelitis." Seminars in neurology. Vol. 28. No. 01. © Thieme Medical Publishers, 2008.
Garg, Nidhi, et al. "Differentiating lower motor neuron syndromes." J Neurol Neurosurg Psychiatry 88.6 (2017): 474-483.
West, Timothy W. "Transverse myelitis—a review of the presentation, diagnosis, and initial management." Discovery medicine 16.88 (2013): 167-177.
Harzheim, Michael, et al. "Discriminatory features of acute transverse myelitis: a retrospective analysis of 45 patients." Journal of the neurological sciences 217.2 (2004): 217-223.