Twelfth cranial nerve involvement in Guillian Barre syndrome
A thirteen year old boy presented with acute progressive areflexic flaccid quadriparesis associated with motor cranial nerve involvement with bilateral facial and bulbar weakness. He had an upper respiratory infection one week preceding the motor weakness which started from the lower limbs. On day seven after the onset of motor weakness of limbs, the child developed significant bulbar weakness, difficulty in talking and could not move the tongue. He was totally anarthric. On day nine, he had significant respiratory muscle weakness requiring mechanical ventilatory support. On day fourteen, bilateral tongue atrophy without fasciculations was noticed []. The nerve conduction studies (NCS) were suggestive of severe demyelinating motor sensory polyradiculoneuropathy. The facial nerve conductions revealed facial neuropathy. His anti-ganglioside antibody panel in the blood showed positive IgM GM2, GT1b, IgG GM1,2,3 and GT1b antibodies. His CSF showed albuminocytological dissociation and his Antinuclear antibody was negative. His magnetic resonance image (MRI) brain was normal. He was treated with intravenous immunoglobulin at a daily dose of 0.4 g/kg for five days. The child required prolonged ventilatory care for 22 days. He showed gradual improvement and started swallowing after eight weeks of the onset of illness. The wasting of the tongue also improved gradually at 3 months after the onset of illness []. At 6 months follow up, he was walking with support with residual bilateral foot drop. Repeat NCS was suggestive of motor sensory demyelinating radiculoneuropathy with improvement in conduction velocities and compound muscle action potential amplitudes compared to baseline study.\nTwelfth nerve involvement, either isolated or as a part of multiple cranial nerve involvement is quite uncommon and only two cases has been reported till date as a part of multiple motor cranial nerve involvement in a case of GBS. Tan et al., reported a case of fulminant GBS with quadriplegia and total paresis of motor cranial nerves and Polo et al., reported a case of atypical GBS with multiple cranial neuropathies including XIIth cranial nerve involvement.