Guillain-Barre syndrome with posterior reversible encephalopathy syndrome
A 63-year-old non-diabetic and non-hypertensive male patient came with complaints of difficulty in walking of five days, inability to do activities of daily living with upper limbs of four days, dysarthria, dysphagia of two days duration, for which he was admitted in the local hospital. On the day of admission he had four generalized tonic-clonic seizures over the interval of 12 h. After the last seizure he did not regain consciousness and was referred to us. There was no history suggestive of sensory and bladder involvement. History was negative for fever, headache, vomiting, rashes, chronic drug intake or addictions.\nOn examination, for first three days the patient was stuporous with high blood pressure of 192/94 mmhg, flaccid limbs and bilateral plantar extensor. On fourth day, the patient regained consciousness and examination revealed bilateral lower motor neuron type of facial and bulbar weakness, hypotonic limbs with power of 1/5 in muscles of the shoulder, arm, hip, thigh and 2/5 in forearm and leg (according to MRC grading) along with the weakness of small muscles of the hand. Deep tendon reflexes were absent without sensory loss.\nOn investigation hemogram, serology, routine biochemistry, chest X-ray, electrocardiogram, echocardiography and abdominal sonography were normal and did not reveal any cause for hypertension. Cerebrospinal fluid analysis showed albuminocytological dissociation with 4-lympocytes, 176 mg/dl-of protein and normal sugar. No organisms were isolated on staining/culture. MRI brain showed bilateral cortical and subcortical altered signal intensities involving the parieto-occipital areas. They were hypointense on-T1W images, hyperintense on-T2W and FLAIR images with no diffusion restriction suggestive of PRES [Figures and ]. Nerve conduction studies showed prolonged latencies, reduced conduction velocity and absent f waves with reduction in the amplitude of compound muscle action potentials with normal sensory potentials suggestive of demyelinating type neuropathy according to HO et al. criteria.\nThe patient was treated with antihypertensives and antiepileptics initially to control his blood pressure and seizures. After resolution of encephalopathy, IVIg was given and his weakness improved over two months. Now after 6-months, the patient is ambulatory and is independent in his daily activities.