Resident Physician NYU Hicksville, New York, United States
Case Diagnosis: Guillain-Barré Syndrome
Case Description: A 62-year-old woman with no significant past medical history presented to the ED with bilateral lower extremity numbness and weakness. She also complained of decreased sensation of urination and numbness of buttocks. She was afebrile and vital signs were stable. On physical exam, she had decreased strength in bilateral lower extremities, distal worse than proximal. She had decreased sensation to pinprick on lower extremities and buttocks and impaired proprioception with position of toes. Deep tendon reflexes in lower extremities were 2+ initially, but faded to trace. Bladder scan revealed urinary retention. MRI of the spine was negative for cauda equina, cord compression, epidural collection, discitis, and osteomyelitis. Lumbar puncture revealed cytoalbuminologic dissociation consistent with Guillain-Barré syndrome. The patient was treated with IVIG with some improvement of symptoms and then underwent acute rehabilitation.
Discussions: Prior to admission, the patient reports that she was in excellent health, exercising daily, with no medical concerns. She denied any preceding illness or vaccination. The patient had significant acute and chronic psychosocial stressors in her life, including an ongoing stressful divorce, domestic abuse requiring protection from her spouse, and recent illness of her beloved family dog. Psychological stress has been associated with changes in the immune system. There is some evidence that toll-like receptor (TLR 4) plays a role between psychosocial stress and pathogenesis of GBS/AIDP, via promotion of Th-2 cytokine release and inflammatory response.
Conclusions: This case sheds light upon a possible trigger for GBS/AIDP which is not entirely understood or fully recognized. It is possible that the patient had a subclinical infection or immune disruption prior to admission. However, the patient's presentation along with her functional history prior to illness and significant, recently worsening stressors appear to suggest that psychosocial stress played a role in the development of GBS/AIDP.
