Keywords:
Cytomegalovirus - Herpesvirus 4, Human - Guillain-Barré Syndrome - Infectious Mononucleosis
Palabras claves:
Citomegalovirus - Herpesvirus Humano 4 - Síndrome de Guillain-Barré - Mononucleosis
Infecciosa
INTRODUCTION
Treatment-related fluctuation (TRF) in patients with Guillain-Barré syndrome (GBS)
describes those cases in which clinical deterioration occurs one or more times after
initial improvement or stabilization with intravenous immunoglobulin (IVIg) or plasmapheresis
(PE) treatment within the first two months after the onset of symptoms ([Figure 1]). This phenomenon affects 5-26% of patients with GBS[1],[2],[3],[4],[5],[6],[7]. Currently, the underlying physiological processes and risk factors related to TRFs
are unknown. These mechanisms could vary according to geographical area[8], due to the different clinical phenotypes or electrophysiological subtypes.
Figure 1 Guillain-Barré definitions and time course: TRF defines the situation when patients
with GBS, previously stabilized or improved with treatment, show clinical deterioration
within two months of the beginning of the pathology. Those patients who have ≥ 3 TRF
or progress clinically after two months from the onset of motor symptoms were excluded
and classified as A-CIDP.A-CIDP: acute-onset chronic inflammatory demyelinating polyneuropathy;
GBS: Guillain-Barré syndrome; T1: starting time of first treatment; T2: time from
the start of relapse to the beginning of the second treatment; TR: time to relapse;
TRF: treatment-related fluctuations.
The objective of our work was to investigate the clinical characteristics and factors
that could increase the risk of relapse by comparing patients with GBS with and without
TRFs.
METHODS
Clinical charts of consecutive patients aged ≥18 years and diagnosed with GBS between
January 2006 and July 2019 in our center (FLENI, Buenos Aires, Argentina) were retrospectively
analyzed. The study was approved by the institutional ethics committee.
Demographic characteristics and past medical history were recorded. Infectious symptoms
or vaccine administration occurring up to one-month before symptom onset were considered
disease triggers. Infectious mononucleosis was considered in cases of fever, pharyngitis,
and adenomegaly due to Epstein-Barr virus (EBV), cytomegalovirus (CMV), or HIV.
Clinical manifestations assessed were pain, motor and sensory deficits, autonomic
dysfunction, and cranial nerve involvement. The Medical Research Council-Sum Score
(MRC-Sum Score)[3] was used to assess motor alterations. Autonomic dysfunction was only considered
when clinical precipitants that could explain these manifestations were ruled out.
An initial cardiovascular evaluation was performed in all patients until clinical
stability was verified. Hemodynamic monitoring was performed four times a day in clinically
stable patients, while those unstable remained in the intensive care unit (ICU) under
continuous cardiovascular monitoring.
Lumbar puncture (LP) and cerebrospinal fluid (CSF) analysis were performed in all
patients during acute illness. Albuminocytologic dissociation was considered present
when CSF-protein level was increased (>45 mg/dL), without CSF-pleocytosis (leukocyte
count of <10/mm3).
All patients underwent electrophysiological nerve conduction studies at least once
within the first four weeks from the onset of symptoms. Amplitude and conduction velocity
were measured after stimulation at conventional sites[9]. Electrophysiological patterns were classified as demyelinating, axonal, or undetermined/normal[10].
Established treatment and delay in administration were analyzed. Disability was assessed
at admission, and 6 and 12 months using the GBS Disability Scale proposed by Hughes[11].
A TRF was defined as[5]: a) improvement in the GBS disability score of at least one grade or improvement
in the MRC sum score of more than 5 points after treatment completion, followed by
a decline in the GBS disability score of at least one grade or a reduction in the
MRC sum score of more than 5 points within the first month after the onset of symptoms;
or b) steady clinical course for more than one week after treatment completion, followed
by a decline of at least one grade of the GBS disability score or more than 5 points
on the MRC sum score.
Patients who had ≥3 TRFs or progressed clinically after two months from the onset
of motor symptoms were excluded and classified as Acute-onset Chronic Inflammatory
Demyelinating Polyneuropathy (A-CIDP)[5].
Differences in demographic and clinical characteristics, ancillary studies, treatment,
and clinical course between both groups were compared using the Wilcoxon rank-sum
test (Stata13v). An alpha value of 0.05 was considered statistically significant.
RESULTS
A total of 124 patients with GBS were included. Seven patients (5.64%) presented TRFs,
with a median age of 53 years (range 32-81 years) and a slight male predominance (57.14%).
There were no significant differences in sex and age among GBS patients with and without
TRFs ([Table 1]). A-CIDP patients were excluded ([Figure 2]). Patients with subacute inflammatory demyelinating polyneuropathy (SIDP) and other
variants of CIDP were also excluded.
Figure 2 Flowchart of patient inclusion.A-CIDP: acute-onset chronic inflammatory demyelinating
polyneuropathy; AIDP: acute inflammatory demyelinating polyneuropathy; AMAN: acute
motor axonal neuropathy; AMSAN: acute motor-sensory axonal neuropathy; GBS: Guillain-Barré
Syndrome; TRF: treatment-related fluctuations.
Table 1
Comparison between GBS patients with and without treatment-related fluctuations.
|
|
Total (n=124)
|
GBS without TRF (n=117)
|
GBS with TRF (n=7)
|
p-value
|
|
Demographic data
|
|
Age in years; median (range)
|
48 (21-86)
|
48 (21-86)
|
53 (32-81)
|
0.51
|
|
Men; n (%)
|
71 (57.26)
|
67 (57.26)
|
4 (57.14)
|
0.99
|
|
Diabetes mellitus; n (%)
|
11 (8.87)
|
9 (7.69)
|
2 (28.57)
|
0.06
|
|
Autoimmune disease; n (%)
|
28 (22.58)
|
27(23.08)
|
1 (14.29)
|
0.59
|
|
Facial paralysis; n (%)
|
8 (6.45)
|
7 (5.98)
|
1 (14.29)
|
0.38
|
|
Oncological disease; n (%)
|
10 (8.06)
|
9 (7.69)
|
1 (14.29)
|
0.53
|
|
HIV; n (%)
|
5 (4.07)
|
5 (4.31)
|
0
|
0.57
|
|
Triggers; n (%)
|
86 (69.35)
|
82 (70.08)
|
4 (57.14)
|
0.47
|
|
Respiratory infection; n (%)
|
41(33.06)
|
40 (34.19)
|
1 (14.29)
|
0.27
|
|
Acute diarrhea; n (%)
|
31 (25.00)
|
30 (25.64)
|
1 (14.29)
|
0.50
|
|
Infectious mononucleosis; n (%)
|
8 (6.45)
|
6 (5.12)
|
2 (28.57)
|
0.01*
|
|
Vaccination; n (%)
|
2 (1.61)
|
2 (1.71)
|
0
|
0.72
|
|
Others; n (%)
|
4 (3.22)
|
4 (3.41)
|
0
|
0.62
|
|
Time from trigger to the first symptom; median days (range)
|
10 (1-30)
|
10 (1-30)
|
5 (3-10)
|
0.10
|
|
Time from trigger to weakness; median days (range)
|
11(1-40)
|
11(1-40)
|
7(3-37)
|
0.48
|
|
Clinical manifestations
|
|
Neuropathic pain; n (%)
|
78 (62.9)
|
71 (60.68)
|
7 (100)
|
0.03*
|
|
Neck MRC; median (range)
|
5 (0-5)
|
5
|
4
|
0.86
|
|
Worst MRC-Sum Score; median(range)
|
51 (0-60)
|
51
|
50
|
0.78
|
|
Sensory disturbances; n (%)
|
110 (88.71)
|
104 (88.89)
|
6 (85.71)
|
0.79
|
|
Paresthesia; n (%)
|
94 (77.69)
|
87 (76.32)
|
7 (100)
|
0.14
|
|
Cutaneous sensory; n (%)
|
50 (41.32)
|
46 (40.35)
|
4 (57.14)
|
0.38
|
|
Proprioceptive sensory; n (%)
|
44 (36.36)
|
42 (36.84)
|
2 (28.57)
|
0.66
|
|
Sensory ataxia; n (%)
|
25 (20.16)
|
23 (19.66)
|
2 (28.57)
|
0.56
|
|
Osteotendinous reflexes
|
|
|
|
|
|
Generalized areflexia; n (%)
|
66 (53.23)
|
61 (52.14)
|
5 (71.43)
|
0.32
|
|
Hyporeflexia/partial areflexia; n (%)
|
50 (40.32)
|
48 (41.03)
|
2 (28.57)
|
0.51
|
|
Normal; n (%)
|
8(6.45)61
|
8(6.48)
|
0
|
0.47
|
|
Autonomic dysfunctions; n (%)
|
43 (34.68)
|
40 (34.19)
|
3 (42.86)
|
0.64
|
|
Severe; n (%)
|
21 (16.94)
|
20 (17.09)
|
1 (14.29)
|
0.84
|
|
HR abnormality; n (%)
|
30 (24.19)
|
28 (23.93)
|
2 (28.57)
|
0.78
|
|
BP changes; n (%)
|
26 (20.97)
|
23 (19.66)
|
3 (42.86)
|
0.14
|
|
Gastrointestinal disturbances; n (%)
|
18 (14.52)
|
15 (12.82)
|
3 (42.86)
|
0.02*
|
|
Genitourinary disturbances; n (%)
|
15 (12.10)
|
14 (11.97)
|
1 (14.29)
|
0.85
|
|
Temperature dysregulation; n (%)
|
10 (8.06)
|
8 (6.84)
|
2 (28.57)
|
0.04*
|
|
CN involvement; n (%)
|
60 (48.39)
|
57 (48.72)
|
3 (42.86)
|
0.76
|
|
Ocular-motility; n (%)
|
11 (8.87)
|
10 (8.55)
|
1 (14.29)
|
0.60
|
|
Facial; n (%)
|
54 (43.55)
|
52 (44.44)
|
2 (28.57)
|
0.41
|
|
Bilateral facial; n (%)
|
30 (24.19)
|
28 (23.93)
|
2 (28.57)
|
0.78
|
|
Lower CN; n (%)
|
10 (8.06)
|
9 (7.69)
|
1 (14.29)
|
0.53
|
|
Multiple CN involvement; n (%)
|
15 (12.12)
|
14 (11.97)
|
1 (14.29)
|
0.85
|
|
CSF and electrophysiological variant characteristics
|
|
Albuminocytologic dissociation; n (%)
|
85 (69.67)
|
79 (68.70)
|
6 (85.71)
|
0.34
|
|
CSF protein level; mg/dL median (range)
|
79.9 (38.6-605)
|
79.9 (38.6-605)
|
90.94 (60-176)
|
0.47
|
|
Time between symptom onset and LP in days; median (range)
|
7 (1-45)
|
7 (1-45)
|
7(2-30)
|
0.60
|
|
EMG classification
|
|
|
|
|
|
AMAN; n (%)
|
4 (3.23)
|
4 (3.23)
|
0
|
0.62
|
|
AMSAN; n (%)
|
7 (5.65)
|
6 (5.13)
|
1 (14.29)
|
0.30
|
|
AIDP; n (%)
|
89 (71.77)
|
83 (70.94)
|
6 (85.71)
|
0.40
|
|
Unclassified/Normal; n (%)
|
18 (14.52)
|
18 (15.38)
|
0
|
0.26
|
|
Miller Fisher; n (%)
|
6 (4.84)
|
6 (5.13)
|
0
|
0.54
|
|
Treatment and evolution
|
|
No treatment requirements; n (%)
|
9 (7.26)
|
9 (7.69)
|
0
|
0.44
|
|
Treatment establishment time in days; median in days (range)
|
7 (1-45)
|
7 (1-45)
|
7(2-30)
|
0.64
|
|
Initial treatment
|
|
|
|
|
|
Immunoglobulin; n (%)
|
112 (90.32)
|
106 (90.59)
|
6 (85.71)
|
0.67
|
|
Plasmapheresis; n (%)
|
3 (2.41)
|
2 (1.70)
|
1 (14.29)
|
0.0349*
|
|
Combined treatment; n (%)
|
10 (8.06)
|
5 (4.27)
|
5 (71.43)
|
<0.001*
|
|
Corticosteroids; n (%)
|
5 (4.03)
|
2 (1.71)
|
3 (42.86)
|
<0.001*
|
|
Admission at ICU; n (%)
|
18 (14.52)
|
16 (13.68)
|
2 (28.57)
|
0.27
|
|
Days in ICU; median (range)
|
0 (0-120)
|
0 (0-120)
|
0 (0-10)
|
0.38
|
|
Orotracheal intubation; n (%)
|
10 (8.06)
|
9 (7.69)
|
1 (14.29)
|
0.53
|
|
Non-invasive ventilation; n (%)
|
5 (4.07)
|
5 (4.31)
|
0
|
0.57
|
|
Hemodynamic support; n (%)
|
6 (4.84)
|
5 (4.27)
|
1 (14.29)
|
0.23
|
|
Baseline GBS disability score; median (range)
|
2 (1-5)
|
2
|
4
|
0.01*
|
|
GBS disability score after 6 months; median (range)
|
0 (0-4)
|
0
|
1
|
0.08
|
|
GBS disability score after 1 year; median (range)
|
0 (0-4)
|
0
|
0
|
0.86
|
|
MRC-Sum Score at discharge; median (range)
|
56 (19-60)
|
56
|
53
|
0.84
|
|
Final MRC-Sum Score; median (range)
|
60 (20-60)
|
60
|
60
|
0.70
|
|
Mortality; n (%)
|
1 (0.81)
|
1 (0.85)
|
0
|
0.80
|
|
Follow-up in months; median (range)
|
36 (6-156)
|
36 (6-132)
|
27 (6-156)
|
0.47
|
AIDP: acute inflammatory demyelinating polyneuropathy; AMAN: acute motor axonal neuropathy;
AMSAN: acute motor-sensory axonal neuropathy; BP: blood pressure; CSF: cerebrospinal-fluid;
CN: cranial nerve; GBS: Guillain-Barré Syndrome; HR: heart rate; ICU: intensive care
unit; LP: Lumbar puncture; MRC: Medical Research Council; TRF: treatment-related fluctuations.
There were no significant differences in past medical history or percentage of patients
who had infectious triggers before GBS. However, those with TRFs had a higher frequency
of infectious mononucleosis before GBS (28.57 vs. 8.55%; p=0.01) ([Table 1]). One of the cases was secondary to cytomegalovirus (CMV), while the other was preceded
by an Epstein Barr Virus (EBV) infection.
Neuropathic pain was the most frequent clinical manifestation in patients with TRFs
(100 vs. 60.68%; p=0.03). There were no significant differences in muscle power, sensory deficits,
and cranial nerve involvement between the two groups. Dysautonomia was slightly more
frequent in patients with TRFs, although the difference was not significant (85.71
vs. 68.70%; p=0.34) ([Table 1]). However, patients with TRFs had a higher frequency of gastrointestinal disorders
(42.86 vs. 12.82%; p=0.02) and temperature dysregulation (28.57 vs. 6.84%; p=0.04).
There were no differences in CSF findings between GBS patients with and without TRFs.
The most frequent electrophysiological presentation in patients with TRFs was acute
inflammatory demyelinating polyneuropathy -AIDP- (85.71%); only one patient presented
an axonal variant. There were no electrophysiological differences between the two
groups ([Table 1]).
Six (85.71%) patients with TRFs received IVIg as the first treatment at a dose of
2 g/kg administered on five consecutive days. Only one (14.29%) received PE (seven
sessions) ([Table 2]). The median delay in treatment administration from symptom onset was seven days
(range 3-30 days), without differences between the two groups. The median time to
first relapse was nine days (range 2-15 days). Only two patients (#4 and #5) switched
the initial treatment. In three cases (#1, #6, and #7), corticosteroids were added
to the IVIg scheme. The median delay in starting the second treatment was 16 days
(2-25 days). Only one patient had more than one relapse. The median total recovery
time from symptom onset was 44 days (range 30-60 days). Patients with TRFs received
PE more frequently than those without TRFs (14.29 vs. 1.70%; p=0.0349). Furthermore, patients with TRFs more frequently required a combination
of treatments (71.43 vs. 4.27%; p<0.001) and the addition of corticosteroids (42.86 vs. 1.71%; p<0.001).
Table 2
Initial and relapse treatment.
|
N°/Age/Sex
|
T1 (days)
|
Initial treatment
|
MRC1/D1
|
TR (days)
|
T2 (days)
|
Relapse treatment
|
Total n° of TRF
|
TT (days)
|
MRC2/D2
|
MRC3/D3
|
|
1/33/M
|
4
|
IVIg (2 g/kg)
|
45/4
|
4
|
16
|
1st relapse: IVIg (2 g/kg)
2nd relapse: corticosteroids
|
2
|
60
|
60/1
|
60/0
|
|
2/32/M
|
9
|
IVIg (2 g/kg)
|
52/2
|
14
|
2
|
IVIg (2 g/kg)
|
1
|
35
|
60/0
|
60/0
|
|
3/71/F
|
7
|
IVIg (2 g/kg)
|
58/3
|
30
|
20
|
IVIg (1 g/kg)
|
1
|
60
|
59/2
|
60/1
|
|
4/81/F
|
14
|
IVIg (2 g/kg)
|
52/4
|
2
|
25
|
PE (5 sessions)
|
1
|
44
|
53/ 2
|
-
|
|
5/53/M
|
2
|
PE (7 sessions)
|
39/5
|
15
|
23
|
IVIg (2 g/kg)
|
1
|
38
|
54/ 2
|
60/0
|
|
6/57/F
|
30
|
IVIg (2 g/kg)
|
50/3
|
4
|
8
|
IVIg (2 g/kg)+corticosteroids
|
1
|
54
|
60/1
|
60/1
|
|
7/46/M
|
3
|
IVIg (2 g/kg)
|
50/4
|
9
|
8
|
IVIg (2 g/kg)+corticosteroids (4 months)
|
1
|
30
|
58/1
|
60/0
|
D1: GBS disability scale prior to treatment; D2: GBS disability scale at 6 months; D3: GBS disability scale at 12 month; F: female; IVIG: intravenous immunoglobulin; M:
male; MRC1: Medical Research Council prior to treatment; MRC2: Medical Research Council at 6 months; MRC3: Medical Research Council at 12 months; PE: plasmapheresis; T1: start time of first treatment; T2: time from the start of relapse to the start of the second treatment; TR: time to relapse; TT: total time to stabilization or improvement; TRF: treatment-related fluctuations.
Patients with TRFs had higher baseline disability scores (4 vs. 2; p=0.01), with a slight non-significant difference at six months (1 vs. 0; p=0.08) ([Table 1]). There were no significant differences in the MRC-Sum Score (initial and final),
ICU admissions, and mortality between groups.
DISCUSSION
The frequency of TRFs in patients with GBS varies according to different series[1],[2],[3],[4],[5],[6],[7]. Original reports with fewer patients suggested that TRFs could occur in up to 26%
of GBS cases[1]. Yet, some of those reports[2],[3] included patients who would be currently characterized as A-CIDP[5]. The most recent series published by the International GBS Outcome Study (IGOS),
which is multicenter and has a substantial sample size[7], showed that the prevalence of TRFs is low (5%). In our series, we observed that
seven (5.64%) of 124 adult patients presented TRFs, in agreement with the results
from the IGOS.
Demographic characteristics and past clinical history were similar between the GBS
groups with and without TRFs ([Table 1]). Interestingly, the GBS group with TRFs was more frequently preceded by infectious
mononucleosis secondary to CMV and EBV (28.57 vs. 8.55%; p=0.01) and showed higher baseline disability scores (4 vs. 2; p=0.01). It has been demonstrated that patients with GBS triggered by CMV and
EBV show more severe clinical manifestations and a greater degree of disability[12]. This could be related to the fact that the immune response mounted after the infection
of these viruses causes a higher concentration of molecules associated with the activation
and migration of “T” cells[12]. However, in that report, no increased risk of TRF was observed when GBS was preceded
by infection with these viruses[12].
On the other hand, other infectious triggers and electrophysiological variants of
GBS are less associated with TRFs. GBS triggered by diarrhea, which causes axonal
variants with anti-GM1 antibodies, had a lower frequency of TRFs[4]. Our population showed similar observations since only one patient with RFT had
diarrhea as an infectious trigger and one patient had an axonal variant ([Table 1]).
The initial clinical manifestations of GBS patients with and without TRF were similar.
Nevertheless, neuropathic pain was reported by all cases of TRF. Most previous reports
on TRF did not consider pain as a manifestation[1],[2],[3],[4],[5],[6]. Only the work by Ruts et al. showed that pain is frequent in patients with TRF
(81%)[7]. Although there were no significant differences in symptoms of dysautonomia between
the two populations, patients with TRFs more often showed gastrointestinal manifestations
and temperature dysregulation. None of the previously mentioned literature reports
have evaluated dysautonomic complications in patients with TRFs[1],[2],[3],[4],[5],[6],[7].
Immunotherapy with IVIg and PE are currently the most effective treatments for GBS[13],[14],[15],[16],[17]. Both treatments have similar efficacy in reducing disability[15],[16]. In our series, patients with TRF were more commonly treated with PE than non-TRF
patients (14.29 vs. 1.70%; p=0.0349). The original study on TRFs was in GBS patients treated only with
PE[1],[2]. These reports attributed TRFs to the fact that immunogenic factors may decrease
early during PE but rise again after the completion of such treatment. However, subsequent
work showed no significant differences in the frequency of TRFs between patients treated
with PE vs. IVIg[3],[4]. Hence, given the small number of GBS patients treated with PE in our series (2.4%),
we cannot confirm or reject the hypothesis that TRFs more frequently occur in patients
treated with PE.
There is insufficient evidence for the re-treatment of patients with GBS and TRFs[7],[17]. Still, physicians often choose to re-treat severe fluctuations[7],[17]. In our series, all patients with TRF were re-treated ([Table 2]). The treatment start time was similar in both groups (median of seven days), so
early treatment was not decisive in relapse. In two cases, the initial treatment was
changed; IVIg treatment was repeated in five patients ([Table 2]). There is insufficient evidence that the combination of IVIg and PE is effective[7],[8],[15],[17] and that a second IVIg course can be used, although there are prospective works
in progress[18]. Besides, three patients (42.86%) with TRFs received empirical corticosteroids in
addition to IVIg treatment. It should be noted that the reason why some patients received
corticosteroids temporarily was that we initially doubted whether they were not patients
with A-CIDP. It is known that corticosteroid treatment is considered ineffective for
GBS patients[19]. However, some studies show slight benefits with the addition of corticosteroids
to IVIG. Nevertheless, due to the retrospective characteristics of our work, it is
not possible to attribute a beneficial effect to treatment with corticosteroids.
In conclusion, in our series, patients with GBS preceded by infectious mononucleosis
and who presented a higher degree of initial disability were at a higher risk of developing
TRFs. Patients with TRFs were treated with PE more frequently than those without TRFs.
Given the small number of patients treated with PE, we cannot affirm that the risk
of TRFs increases with its use.
