Abstract
Guillain-Barré syndrome (GBS) is the most common acute inflammatory motor polyneuropathy. It affects all age groups, but the incidence increases with increasing age. Before manifesting with neurological symptoms, it is usually preceded by a prodromal phase of infection, most commonly respiratory or gastrointestinal. Pathologically, it is a post-infection immune disorder. The immune response is due to mimicry between the infecting agent and axolemmal surface molecules, which triggers an acute immune injury that leads to blockade of nerve conduction. Age-related decline in immune function plays a role in the increased prevalence and severity of GBS in older people. Typical neurological manifestations are ascending paralysis, areflexia and cranial nerve involvement, but sensory loss is uncommon. In up to 25% of cases, autonomic dysfunction occurs, which includes cardiovascular, sudomotor, gastrointestinal or genitourinary symptoms. The development of autonomic dysfunction in GBS is associated with poor prognosis. We report a case of a 78-year-old man who presented with a predominant autonomic dysfunction that led to a delay in the diagnosis. Because of the multiple morbidities associated with old age, the diagnosis of GBS presentation with autonomic dysfunction, without the typical neurological clinical pattern, may be attributed to the existing comorbidities. Therefore, clinical suspicion and close monitoring with respect to the development of autonomic dysfunction, from the first day of hospital admission, are important. The main diagnostic tests are cerebrospinal fluid analysis looking for protein-cell dissociation and nerve conduction studies to confirm the neuropathy. Treatment involves general supportive care, specific immunological intervention by intravenous immunoglobulins or plasma exchange courses and neurorehabilitation. Severe cases may require intensive care admission and mechanical ventilation. More than 80% of cases will fully recover, but 10% may have residual disability, with mortality estimated at 3-7%. Older age, multiple morbidities, severe weakness, autonomic dysfunction and the need for mechanical ventilation are poor prognostic factors.