GUILLAIN‐BARRÉ SYNDROME IN ELDERLY PEOPLE

Abstract

To the Editor: A 92-year-old woman presented with reduced mobility following an Escherichia coli urinary tract infection. She had previously ambulated independently using a cane. On presentation, she ambulated using a four-wheeled frame. Apart from mild weakness in both legs and generalized brisk reflexes in all limbs, her neurological examination was unremarkable. Computed tomography of the brain showed small vessel ischemia but no acute changes. During the following 10 days, she developed several episodes of diarrhea. Fecal microscopy, culture, and viral polymerase chain reaction were negative. She became progressively weak in all limbs and nonambulatory. Upper limb and knee reflexes remained brisk, but ankle jerks and plantar responses were absent. Sensation was impaired in glove and stocking distribution. Mild weakness in facial movement was noted. On Day 10, a magnetic resonance imaging scan of the cervical cord showed severe central canal stenosis from C3/4 to C5/6 without cord signal change. A nerve conduction study demonstrated markedly reduced compound motor action potentials in all limbs consistent with acute motor axonal neuropathy (a variant of Guillain-Barré syndrome). She declined lumbar puncture. Anti-GM1 antibody was negative. It was concluded that Guillain-Barré syndrome accounted for her rapid neurological decline, and cervical myelopathy contributed to hyperreflexia and to some degree of her baseline limb weakness. She was treated with a 5-day course of intravenous immunoglobulin, which she tolerated without complications. She ambulated independently with a four-wheeled frame after 6 weeks of rehabilitation. Guillain-Barré syndrome is an immune-mediated neuropathy. The age-specific curve shows a bimodal distribution, with peaks in incidence in young adults (aged 15–34) and in elderly people (aged 60–74). The first peak correlates with the increased risk of cytomegalovirus and Campylobacter jejuni infection in young adults. The peak in elderly people may be related to failing immune suppressor mechanisms, resulting in increased susceptibility to autoimmune disorders.1 In one study, Guillain-Barré syndrome was found to be the third most common cause of polyneuropathy in people aged 65 and older (11% of cases), after diabetes mellitus and neoplasm.2 Diagnosis of Guillain-Barré syndrome in elderly people is easily overlooked. The coexistence of other neurological and nonneurological diseases may alter the manner in which the syndrome presents. Early symptoms and signs are more likely to be dismissed in elderly people. Delayed presentation may occur because of difficulty in obtaining access to referral services.3 Antecedent illness, occurring in approximately two thirds of younger patients, is reported less frequently and is of shorter duration in elderly people. The interval between onset and peak severity was shorter in elderly patients, but no significant differences in disease severity have been reported.3,4 The most common manifestation is acute onset of symmetrical limb weakness with areflexia (in 90%). Symptoms related to peripheral nerve damage, such as paraesthesia, myalgia, and limb weakness, occur with similar frequency in younger and older patients, whereas ophthalmoplegia and facial weakness occurred less often in elderly people.3 Guillain-Barré syndrome has several variant forms, with acute inflammatory demyelinating polyradiculoneuropathy being the most common (85–90% of cases). Acute motor axonal neuropathy, accounting for 5% to 10% of cases, occurs with higher frequency in elderly people (up to 40%).5 Immunomodulation is the first-line therapy, with trials showing similar effectiveness of plasmapheresis and intravenous immunoglobulin (IVIg). Elderly patients treated with IVIg tend to take longer to reach nadir of neurological deficits and have longer hospital stays than those treated with plasmapheresis. Severe complications, such as hypotension, abnormal clotting, and complications related to central venous access, are noticed in 30% of patients treated with plasmapheresis. Patients treated with IVIg usually do not experience major complications.4 Based on these findings, IVIg is preferable to plasmapheresis in elderly people, because it is safer, more convenient, equally effective, and of comparable overall cost.6 Age of 60 and older is a poor prognostic factor.7 Of patients admitted to intensive care units, those who die are older and more likely to have underlying pulmonary disease.8 The duration of hospital stay is greater, and the number of days needed for functional improvement is longer in elderly people.3,9 It has not been found that age affects the relapse rate.7 Guillain-Barré syndrome is underrecognized in elderly people, warranting a high index of suspicion. Large multicenter prospective studies are needed to provide better understanding of Guillain-Barré syndrome in elderly people, particularly in the oldest-old. Conflict of Interest: The editor in chief has reviewed the financial and personal conflict of interest checklist and has determined that the author has no conflicts of interest related to this letter. Author Contributions: Author is sole contributor for this letter. Sponsor's Role: None.