Guillain-Barré syndrome physical examination


 * Associate Editors-In-Chief: Priyamvada Singh, MBBS [mailto:psingh@perfuse.org]

Overview
Guillain-Barré syndrome (GBS) is an acute, autoimmune, polyradiculoneuropathy affecting the peripheral nervous system, usually triggered by an acute infectious process. It is included in the wider group of peripheral neuropathies. The physical examination findings usually indicates features due to autonomic dysfunction and demyelination of peripheral nerves. Fluctuation in vitals can be seen and may present as hyper or hypothermia, hypo or hypertension, brady or tachycardia. Progressive, symmetric, bilateral, flaccid, ascending paralysis progressing over weeks to days time is the common finding. Hypotonia, hyporeflexia, areflexia can be seen.Sensory system may be involved but generally it is mild. Ataxia and difficulty in walking may be seen despite great muscle strength due to involvement of proprioception and oculoparesis.

General physical examination
The findings on physical examination indicates features of autonomic dysfunction and weakness of respiratory muscles

Vitals

 * Hyperthermia or hypothermia either could be present.
 * Tachypnea due to respiratory failure could be observed.
 * Tachycardia or bradycardia may be observed
 * Hypertension or hypotension can be observed.

Cranial nerve

 * Facial palsy (cranial nerve VII involvement) is the most commonly found.
 * Other findings like dysphagia (cranial nerve IX, X, and XI), dysarthria (cranial nerve X), ocular muscle palsy (VI), Ptosis (III}, and Pupillary abnormalities (Tonic pupils) (II) may be seen.

Nutrition
The muscle bulk is normal earlier in the course of the disease. However, later with disease progression muscle atrophy may be found.

Tone

 * Hypotonia may be seen associated with severe weakness

Power

 * Progressive, symmetrical, ascending palsy involving proximal muscles earlier than distal muscles are the most common findings.
 * The weakness usually starts with lower limb followed by trunk, upper limb, and cranial nerve. In Miller-Fischer variant though cranial nerves are involved earlier than the limbs.

Coordination

 * The patient may have difficulty walking despite having a good power. This may be due to involvement of proprioceptive and ocular muscles.

Sensory system

 * Though the first presenting symptoms may be dysthesia, severe sensory involvement is unusal. A definitive sensory level findings put the diagnosis of GBS into question.

Reflexes
Hyporeflexia or Areflexia can be commonly seen

Diagnostic criteria

 * Required
 * Progressive, relatively symmetrical weakness of 2 or more limbs due to neuropathy
 * Areflexia
 * Disease course < 4 weeks
 * Exclusion of other causes (see below)
 * Supportive
 * relatively symmetric weakness accompanied by numbness and/or tingling
 * mild sensory involvement
 * facial nerve or other cranial nerve involvement
 * absence of fever
 * typical CSF findings obtained from lumbar puncture
 * electrophysiologic evidence of demyelination from electromyogram