Recurrent Guillain-Barré Syndrome Research Articles

Differentiating recurrent Guillain-Barre syndrome and acute-onset chronic inflammatory polyneuropathy: literature review.

Guillain-Barre syndrome (GBS) is an acute-onset immune-mediated polyneuropathy characterized by ascending symmetrical muscle weakness, diminished reflexes, and sensory symptoms. While GBS typically follows a monophasic course, some patients experience treatment-related fluctuations or recurrences, posing diagnostic challenges in distinguishing GBS from acute-onset chronic inflammatory polyneuropathy (A-CIDP). A-CIDP, may present acutely, simulating GBS, with a nadir in less than 8weeks, subsequently evolving into a chronic or relapsing course. The distinction between recurrent GBS and A-CIDP is crucial, as A-CIDP necessitates long-term immunosuppression. A PubMed search was conducted using the search terms 'recurrent Guillain Barre syndrome' and 'acute onset CIDP' focusing on studies in theEnglish language, published between January 1, 2004 and April 30, 2023. Overlapping clinical features, particularly in the early stages, complicate differentiation between recurrent GBS and CIDP. Electrophysiological studies, ultrasonography, and immunological markers have been explored for discrimination; however, definitive criteria for differentiation remain elusive. Recent follow-up studies have further blurred the boundaries between recurrent GBS and A-CIDP, suggesting the persistence of underlying immune processes even in GBS patients without clinical deterioration. This emphasizes the necessity of reevaluating diagnostic criteria and treatment strategies. In conclusion, distinguishing recurrent GBS from A-CIDP remains an ongoing challenge. Existing evidence questions the categorization of recurrent GBS as a distinct entity, challenging its very existence. Continued research is necessary to refine diagnostic criteria and deepen our understanding of these conditions, ultimately advancing patient care. This review delves into the intricacies of recurrent GBS and A-CIDP differentiation and highlights the need for a reevaluation of therecurrent GBS concept.

Complement-membrane regulatory proteins are absent from the nodes of Ranvier in the peripheral nervous system

BackgroundHomozygous CD59-deficient patients manifest with recurrent peripheral neuropathy resembling Guillain-Barré syndrome (GBS), hemolytic anemia and recurrent strokes. Variable mutations in CD59 leading to loss of function have been described and, overall, 17/18 of patients with any mutation presented with recurrent GBS. Here we determine the localization and possible role of membrane-bound complement regulators, including CD59, in the peripheral nervous systems (PNS) of mice and humans.MethodsWe examined the localization of membrane-bound complement regulators in the peripheral nerves of healthy humans and a CD59-deficient patient, as well as in wild-type (WT) and CD59a-deficient mice. Cross sections of teased sciatic nerves and myelinating dorsal root ganglia (DRG) neuron/Schwann cell cultures were examined by confocal and electron microscopy.ResultsWe demonstrate that CD59a-deficient mice display normal peripheral nerve morphology but develop myelin abnormalities in older age. They normally express myelin protein zero (P0), ankyrin G (AnkG), Caspr, dystroglycan, and neurofascin. Immunolabeling of WT nerves using antibodies to CD59 and myelin basic protein (MBP), P0, and AnkG revealed that CD59 was localized along the internode but was absent from the nodes of Ranvier. CD59 was also detected in blood vessels within the nerve. Finally, we show that the nodes of Ranvier lack other complement-membrane regulatory proteins, including CD46, CD55, CD35, and CR1-related gene-y (Crry), rendering this area highly exposed to complement attack.ConclusionThe Nodes of Ranvier lack CD59 and are hence not protected from complement terminal attack. The myelin unit in human PNS is protected by CD59 and CD55, but not by CD46 or CD35. This renders the nodes and myelin in the PNS vulnerable to complement attack and demyelination in autoinflammatory Guillain-Barré syndrome, as seen in CD59 deficiency.

Recurrent Guillain-Barré Syndrome Associated with the Second Episode of Campylobacter jejuni Infection.

Guillain-Barré syndrome (GBS) cases are generally monophasic, and recurrence is rare. However, the pathogenesis and pathophysiology of recurrent GBS remain to be fully elucidated. There are few detailed reports of patients who have been infected twice with Campylobacter jejuni and have developed GBS twice. We herein report a case of recurrent GBS in a 21-year-old man with a history of GBS caused by C. jejuni infection at 19 years old. Although our patient was reinfected with C. jejuni, several different anti-ganglioside antibodies were identified, and the clinical manifestations were more severe than those in the first GBS episode. We compared the anti-ganglioside antibodies and nerve conduction studies findings between the two GBS episodes. This case suggested that different antibodies are involved and produce different symptoms even when C. jejuni infection is the trigger in recurrent episodes.

1851. Recurrence of Streptococcus agalactiae Bacteremia - Risk Factors and Complications

Abstract Background The primary objective was to identify the frequency of recurrent Streptococcus agalactiae (GBS) bacteremia and associated risk factors for recurrence. The secondary objective was to determine the source of the initial GBS bacteremia and complications. Methods This was a retrospective observational study evaluating patients who were admitted to any of the 12 hospitals within the Northwell Health System from 1/1/2016 to 1/1/2020. Non-pregnant patients ≥ 18 years of age with GBS bacteremia were included. Recurrence was defined as admission due to GBS bacteremia within 1 year after a positive blood culture. Statistical methods performed include t-test or Wilcoxon Rank Sum test, Chi-square, Fisher exact tests, and both univariable and multivariable logistic regressions. Results 390 patients met inclusion criteria with a median age of 63 years old. Majority were white (61.5%) and male (54.1%). Recurrence was found in 18 of 390 patients (4.62%). There was a significant increase in recurrence for patients allergic to penicillin or cephalosporins (p< 0.03), patients with implantable cardiac devices (ICDs) (p< 0.03) and patients who did not receive β-lactams and/or vancomycin as initial treatment (p< 0.05). 6 of the 18 patients were allergic to penicillin or cephalosporins. The estimated odds of recurrence in patients with ICDs were ∼5.4 times the odds of those without ICDs controlling for allergies (p< 0.04, 95% CI 1.7 – 20.0) or controlling for initial antimicrobial treatment (p< 0.04, 95% CI 1.5 – 18.7). The most common sources of GBS bacteremia were skin and soft tissue (35.1%), unknown (27.9%), and urinary tract (6.41%). Endocarditis was diagnosed in 8 patients (2.05%) via transesophageal echocardiogram. Other complications of GBS bacteremia included vertebral osteomyelitis (3.08%), epidural abscess (0.77%), and septic arthritis (0.77%). Median treatment duration was 15 days, with no significant difference in recurrence (p=0.75). Conclusion GBS bacteremia recurred in 4.62% of patients. Recurrence was significantly associated with ICDs, penicillin or cephalosporin allergies, and not receiving β-lactam and/or vancomycin-based regimens as initial therapy. The substantial rate of recurrent GBS bacteremia has important clinical implications. Disclosures All Authors: No reported disclosures.

Recurrent Guillain-Barré syndrome presenting as pharyngeal-cervical-brachial variant with three species of ganglioside antibodies:case report

BackgroundGuillain-Barré syndrome (GBS) is generally considered to be monophasic, and recurrent GBS (RGBS) is very rare. Pharyngeal-cervical-brachial (PCB) is a less common variant of GBS. There have been no cases reported describing RGBS showing different phenotype presenting as PCB variant with three species of ganglioside antibodies.Case presentation We report a case of a 77-year-old female patient with GT1a, GD1a and sulfatide-seropositive PCB-GBS after prior episode of AMAN-GBS 13 years ago. Our patient showed oropharyngeal and cervicobrachial weakness associated with areflexia in the upper limbs and partially improved after 5 days of IVIG and physiotherapy.ConclusionThis study reports a rare case characterized as recurrent GBS after a long period, showing different phenotypes in different episodes with three different species of ganglioside antibodies. Further studies are required to obtain better understanding of RGBS and PCB variant.

Recurrence of a Rare Subtype of Guillain-Barré Syndrome Following a Second Dose of the Shingles Vaccine

Guillain-Barré Syndrome (GBS) is an acute, immune-mediated polyneuropathy. The exact cause of GBS remains unknown, however, it commonly develops post-infection. Since the 1950s, various vaccines have been attributed to causing the syndrome, yet no definitive relationship has ever been determined. In 2021, the Food and Drug Administration (FDA) placed a black-box warning for Shingrix, a non-live recombinant vaccine against the varicella-zoster virus, regarding a possible risk of acquiring GBS post-vaccination in adults aged 65 and older. We report the recurrence of a rare subtype of GBS in a 61-year-old patient following the second dose of Shingrix. This case highlights the difficulty of diagnosing and treating recurrent GBS. It also raises awareness that Shingrix may be related to the development of GBS in younger patients. This case also emphasizes the importance of differentiating GBS from other polyneuropathies.

ACUTE FLACCID PARALYSIS-REVIEW OF CASES WITH DIVERSE PRESENTATIONS

This study was done in 50 patients at the department of neurology,Madurai medical college,Govt rajaji hospital from March 2019 to august 2019.AFP cases were diagnosed based on detailed history including onset,duration,precipitating factors,relieving factors,risk factors, recurrences ,associated symptoms and physical examination. The underlying etiology was ascertained by appropriate laboratory investigations such as RBS, serum potassium levels, CSF analysis, electrophysiological studies and Neuro imaging. Most of the patients belonged to Mean age group 21 to 40yrs 19(38%). Data was collected and statistical analysis was done.Males constituted 78% (39/50) and females constituted 22% (11/50). Out of 50 patients,14(28%) were suffering from Acute Inflammatory Demyelinating Polyneuropathy(AIDP), 4(8%) from Acute motor axonal neuropathy(AMAN), 3(6%) from Road traffic accident( RTA), 3(6%) from Hypokalemic periodic paralysis(HPP),3(6%)from snake bite,2(4%) from post vaccination induced AIDP,2(4%)from Miller fisher variant,2(4%) from NMOSD,2(4%) from recurrent GBS,2(4%)from transverse myelitis,2(4%) from diabetic polyradiculopathy, others 11(22%). AIDP was the most common cause of AFP in all age groups. Good prognosis noted in these group of patient 26(52%)

Serum thyroid-stimulating hormone is an independent risk factor of recurrent Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is generally considered to be monophasic, but some patients have recurrences. The purpose of this study was to clarify the possible link between thyroid parameters and recurrent GBS (RGBS) patients in China. In this retrospective study we enrolled patients who were admitted to the Department of Neurology of The First Affiliated Hospital of Zhengzhou University from 2014 to 2020 and fulfilled the diagnostic criteria of GBS or Miller Fisher syndrome. We evaluated clinical characteristics; cerebrospinal fluid parameters; and serum levels of thyroid-stimulating hormone (TSH), free thyroxine, and free triiodothyronine in 320 individuals, including 302 with monophasic GBS and 18 with recurrent GBS. Serum levels of TSH in monophasic GBS patients were significantly lower than those in RGBS patients (P< .001), whereas FT3 levels were higher in the monophasic GBS group (P= .022). Age at onset, incidence of antecedent illness, time from onset to nadir, proportion with acute inflammatory demyelinating polyradiculoneuropathy, and Hughes Functional Grading Scale score at nadir were statistically significant between monophasic GBS patients and RGBS patients (P< .05). The multivariate regression analysis revealed that antecedent illness, AIDP, and high TSH were independent risk factors for RGBS. Our receiver-operating characteristic curve analysis showed that the risk of recurrence in GBS patients increases when the TSH concentration is higher than 3.87 μIU/mL. Our results demonstrate an association between TSH and RGBS. Oxidative stress is one of the possible interpretations for this association.

Recurrent Group B Streptococcus Septicemia Secondary to Portal Hypertensive Colopathy

Background Group B streptococcal infections (GBSs) in nonpregnant adults have become an increasingly recognized entity. Bacteremia without focus has consistently been demonstrated as the second leading cause of infection. Recurrent bacteremia, however, remains a significantly rarer phenomenon, and underlying mechanisms and risk factors are poorly elucidated in the literature. Case Report We report the first case of 3 independent episodes Streptococcus agalactiae bacteremia without focus, in 56-year-old woman with Child-Pugh B cirrhosis and the uncommon finding of portal hypertensive colopathy. Results We propose bowel hemorrhage secondary to portal hypertensive colopathy, facilitated recurrent bacterial translocation and blood stream infection in this immunocompromised host, presenting as recurrent bacteremia without focus. We discuss the disease epidemiology of GBS infections, antibiotic sensitivity, and risk factors for infection relating to this theory in a literature review. Conclusions Portal hypertensive colopathy in liver cirrhosis may contribute to underlying risk for recurrent GBS bacteremia without focus that necessitates prolonged penicillin class antibiotic therapy.

Case Series of Guillain-Barré Syndrome After the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) Vaccine.

Vaccination has been associated with Guillain-Barre syndrome (GBS). Amid a global vaccination campaign to stop the spread of COVID-19, fears of GBS can contribute to vaccine hesitancy. We describe 3 cases of GBS in Calgary, Canada, presenting within 2 weeks of receiving the ChAdOx1 nCoV-19 (COVISHIELD) Oxford-AstraZeneca vaccination and review the available literature. All 3 patients presented to the hospital in Calgary, Alberta, Canada, within a one-month time frame with GBS. Their clinical courses ranged from mild to severe impairment, all requiring immunomodulatory treatment. There is currently little evidence to support a causal relationship between vaccination and GBS. Furthermore, there is limited evidence to support recurrent GBS in patients with GBS temporally associated with vaccination. Neurologists should approach discussions with patients regarding GBS after vaccination carefully so as not to misrepresent this relationship and to educate patients that the risk of COVID-19 infection outweighs the small individual risk of a vaccine-associated adverse event.

Association between serum low‐density neutrophils and acute‐onset and recurrent Guillain–Barré syndrome

Background and AimGuillain–Barré syndrome (GBS) is one of the most common causes of acute flaccid paralysis. A timely assessment of this disease condition and its treatments are of vital importance to patients diagnosed with GBS. The purpose of this study is to investigate the variation trend of neutrophils along with disease courses and assess the prognostic value of serum low‐density neutrophils (LDNs) in the acute‐onset and recurrence of GBS.MethodsA total of 176 GBS patients were recruited. Patients were evaluated with Medical Research Council (MRC) sum score and the Hughes Functional Grading Scale score upon admission. Peripheral blood samples were collected for routine testing. Flow cytometry analysis was performed to identify LDNs. All patients were followed up to collect disease condition data.ResultsThe total neutrophil ratios and counts were significantly higher in patients with acute‐onset GBS compared to healthy controls (HCs). These counts/ratios decreased during remission and re‐elevated in recurrent GBS patients. However, no correlation was observed between the total neutrophil counts/ratios and the MRC sum score. The LDNs collected from different GBS courses were identified using flow cytometry. The counts and ratios were significantly higher in acute‐onset GBS and recurrent GBS compared to HCs and patients in remission. The LDN counts/ratios displayed a negative correlation with the MRC sum scores in acute‐onset GBS and recurrent GBS.ConclusionOur findings suggest that LDN counts/ratios are positively correlated with the acute‐onset and recurrence of GBS and its severity. Therefore, LDNs might serve as an accessible prognostic indicator for disease progression monitoring.

Reworsening of Recurrent Guillain-Barré Syndrome Triggered by COVID-19 Infection

Introduction: Guillain-Barré Syndrome (GBS) is an acute, immune-mediated, generalized polyradiculoneuropathy often triggered by a bacterial or viral infection, vaccination, or surgery. During the SARS-CoV-2 pandemic, some patients were reported with GBS associated COVID-19 infection. Case Presentation: We report, herein, a patient who had a recurrent GBS after forty years. Intravenous immunoglobulins (IVIg) induced improvement, but her condition worsened suddenly after twenty days, coinciding with a COVID-19 infection. A second IVIg cycle was administered, and she improved again. Conclusion: The take-home message is that in the current pandemic, any re-worsening or lack of improvement after appropriate treatment of GBS or possibly other autoimmune neurological diseases must be checked to determine if it is related to COVID-19 infection.

CLINICAL-EPIDEMIOLOGICAL CHARACTERIZATION OF GUILLAIN BARRÉ SYNDROME IN A CUBAN CASE SERIE.

Background: The broad spectrum of Guillain Barré Syndrome (GBS) includes different pathological phenotypes, with a heterogeneous distribution. The reports, by country and region, have shown its great variability and clarified its behavior.Objective: Characterize GBS and define the most frequent phenotypes.Methods: A time series was constructed to analyze the epidemiological behavior of GBS. The demographic, epidemiological, clinical and complementary aspects of 167 patients were retrospectively described. The severity was analyzed and the patients were classified.Results: The mean age was 33 years, 22.8% were children. The incidence decreased with age and a seasonal preference was seen for the month of August, that usually coincides with higher rates of respiratory and digestive infections. Dengue preceded some GBS outbreaks. The Acute Inflammatory Demyelinating Polyradiculopathy (AIDP) variant predominated and was most severe. Regional variants, a recurrent GBS and a family one were detected. Age, personal history of autoimmune disease, preceding infectious phenomenon, latency between the preceding phenomenon and the onset of the clinical picture, the extent of the motor disorder, facial involvement, gait impairment, ventilatory compromise, and degradation of the osteotendinous reflexes, significantly correlated with the severity.Conclusions: The predominance of AIDP coincides with some countries in the area, with varying geographical location and climatic conditions. The incidence decreases with age. The relationship between the severity and the personal history of autoimmune disease, the preceding infectious phenomenon, and the latency between the preceding phenomenon and the onset of the clinical picture, could be reflecting an underlying autoimmune mechanism in each case.

Antiparanodal antibodies and IgG subclasses in acute autoimmune neuropathy.

ObjectiveTo determine whether IgG subclasses of antiparanodal autoantibodies are related to disease course and treatment response in acute- to subacute-onset neuropathies, we retrospectively screened 161 baseline serum/CSF samples and 66 follow-up serum/CSF samples.MethodsWe used ELISA and immunofluorescence assays to detect antiparanodal IgG and their subclasses and titers in serum/CSF of patients with Guillain-Barré syndrome (GBS), recurrent GBS (R-GBS), Miller-Fisher syndrome, and acute- to subacute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP). We evaluated clinical data retrospectively.ResultsWe detected antiparanodal autoantibodies with a prevalence of 4.3% (7/161), more often in A-CIDP (4/23, 17.4%) compared with GBS (3/114, 2.6%). Longitudinal subclass analysis in the patients with GBS revealed IgG2/3 autoantibodies against Caspr-1 and against anti–contactin-1/Caspr-1, which disappeared at remission. At disease onset, patients with A-CIDP had IgG2/3 anti–Caspr-1 and anti–contactin-1/Caspr-1 or IgG4 anti–contactin-1 antibodies, IgG3 being associated with good response to IV immunoglobulins (IVIg). In the chronic phase of disease, IgG subclass of one patient with A-CIDP switched from IgG3 to IgG4.ConclusionOur data (1) confirm and extend previous observations that antiparanodal IgG2/3 but not IgG4 antibodies can occur in acute-onset neuropathies manifesting as monophasic GBS, (2) suggest association of IgG3 to a favorable response to IVIg, and (3) lend support to the hypothesis that in some patients, an IgG subclass switch from IgG3 to IgG4 may be the correlate of a secondary progressive or relapsing course following a GBS-like onset.

Recurrent Late-Onset GBS Sepsis in the NICU

Recurrent Late-Onset GBS Sepsis in the NICU

Recurrent neonatal group B streptococcus cellulitis and adenitis syndrome with late-onset sepsis

Abstract Objectives Group-B streptococcus (GBS) continues to be a significant cause of late-onset neonatal illness. Rarely does it present as cellulitis-adenitis syndrome, and rarely does the infection recur in the same infant after complete recovery. Case presentation Here we report a case of recurrent late-onset cellulitis-adenitis GBS syndrome in a term 12-day-old neonate. The infant presented with fever and cellulitis of the right neck. Full sepsis workup was normal and the infant recovered completely with antibiotics. Three days after the completion of antibiotics the patient returned to the emergency department due to fever, toxic appearance and rapidly spreading cellulitis, and adenitis on the left side of the neck. Blood culture revealed GBS. The patient was re-admitted to the hospital and successfully treated with a prolonged course of antibiotics. Conclusions This case highlights the importance of treating neonatal cellulitis with fever as bacteremia, and reminds us of the rare possibility of recurrent invasive GBS disease. Moreover, this case illustrates that GBS cellulitis-adenitis syndrome is possibly underdiagnosed in mild cases. Physicians should be aware that neonatal cellulitis can precede the appearance of severe sepsis. Neonates with fever and cellulitis without a clear external port of entry should undergo a complete sepsis workup and receive antibiotic treatment appropriate for bacteremia, even if the blood cultures are negative. Although the recurrence of GBS sepsis is rare, physicians should be aware of this possibility in order to treat the infection early.

A RARE CASE OF RECURRENT GUILLAIN BARRE SYNDROME.

After the reduction of poliomyelitis, Guillain–Barre syndrome (GBS) has become the most common cause of acute flaccid paralysis in the developed and developing countries. Although it is a monophasic illness, GBS might reoccur in 1–6% of patients, after an asymptomatic period of several months to years. Risk factors for recurrent GBS (RGBS) include age less than 30, milder symptoms, and history of Miller-Fisher syndrome variant in the first episode. A recurrence was defined as two or more episodes that fulfilled the National Institute of Neurological and Communicative Disorders and Stroke criteria for GBS, with a minimum time between episodes of 2 months (when fully recovered in between) or 4 months (when only partially recovered). There appears to be no significant difference between GBS and RGBS episodes with respect to clinical symptoms and triggering events. We report a 12-year-old girl who presented with a second attack of GBS after an interval of 6 years with similar signs and symptoms. Nerve conduction study in both the episodes was of acute motor axonal neuropathy variety.

Impact of Interdisciplinary Rehabilitation in a Patient with Recurrent Guillain Barre Syndrome: A Case Report

To understand the effect and importance of individualized interdisciplinary rehabilitation in the recovery of patients with recurrent GBS.

Anti-ganglioside complex antibody profiles in a recurrent complicated case of GQ1b-seronegative miller fisher syndrome and Bickerstaff brainstem encephalitis: a case report

BackgroundGuillain-Barré syndrome (GBS), Miller Fisher syndrome (MFS) and Bickerstaff brainstem encephalitis (BBE) are a group of autoimmune neurological disorders (GBS spectrum disorder) that rarely recur. Recently, anti-ganglioside complex antibodies (GSC-Abs) were identified in patients with GBS spectrum disorder. However, there has been no case report describing GSC-Abs profiles in a recurrent case showing different phenotypes.Case presentationWe report the case of a 33-year-old male patient with GQ1b-seronegative BBE-GBS after two prior episodes of MFS-GBS. Our patient showed ophthalmoplegia, ataxia, areflexia and a weakness of the extremities (MFS and GBS symptoms) in all episodes. In the episode reported here, our patient showed disturbed consciousness and an extensor response to cutaneous plantar stimulation was observed (BBE symptoms), with severe disability and requirement for artificial respiration management. GSC-Abs detected in previous episodes were also detected in the subsequent episodes, while new GSC-Abs emerged in each episode. Interestingly, whereas antibodies to GA1/GQ1b and GA1/GT1a, which are commonly identified in patients with GBS, MFS or BBE, appeared in all episodes, antibodies to GD1a/GD1b and GD1b/GT1b, which are predominantly associated with severe disability and the requirement for artificial respiration management in GBS, emerged for the first time in this episode.ConclusionThis study reports novel phenomena about the GSC-Abs profiles and its relationship with clinical features in a case with recurrent GBS spectrum disorder, showing different phenotypes in different episodes. Further studies are required to reveal the significance of the GSC-Abs profiles in recurrent GBS spectrum disorder.

A case of a recurrent GBS

Background: Guillain-Barré syndrome is an acquired polyradiculo-neuropathy, often preceded by an antecedent event. It is a monophasic disease but a recurrence rate of 1–6 % is documented in a subset group of patients.Case presentation: Thirty-five-years-old female with past history of near complete recovery following Guillain-Barré syndrome 17 years back presented with acute, ascending symmetrical flaccid quadriparasis extending to bulbar muscles and respiratory compromise needing mechanical ventilation. Nerve conduction study revealed AMAN variant of Guillain-Barré syndrome. Cerebrospinal fluid analysis done after 1 weeks during recurrent episode revealed albuminocytologic dissociation. She was treated with intravenous immunoglobulin resulting in a remarkable recovery.Conclusion: Recurrence of Guillain-Barré syndrome can occur in a subset of patients with Guillain-Barré syndrome even after many years of asymptomatic period. Most patients with recurrent GBS respond favourably to treatment with plasmapheresis or IVIG.Bangladesh Crit Care J September 2017; 5(2): 135-138