Guillain-Barre Syndrome — DCE Clinical Case

DCE long case

Patient brief (provided to trainee)

Patient: a 54-year-old man, three months after severe Guillain-Barré syndrome following Campylobacter enteritis. He was ventilated and received a tracheostomy, and was treated with IVIg. He now sits in a wheelchair, has a capped tracheostomy, symmetric distal weakness, absent reflexes and burning foot pain.^[1]

Candidate's structured presentation (model)

"This man is recovering from severe GBS. His problems are residual weakness, tracheostomy weaning, neuropathic pain, and the psychological aftermath of a long ICU stay."^[1]

Prolonged ventilation is expected in severe GBS: in 60 ventilated patients, only 22 per cent were weaned within 3 weeks and 87 per cent had a tracheostomy.^[4]

Management plan

1. Rehabilitation and recovery expectations. After a plateau of days to months, patients recover; about 80 per cent walk independently at 6 months. Limb contractures, ossification and pressure palsies need prevention.^[1]
2. Pain. EAN/PNS weakly recommends gabapentin or carbamazepine, advising gabapentinoids or tricyclic antidepressants before carbamazepine.^[2]
3. Psychological care. Pain, hallucinations, anxiety and depression are frequent in GBS.^[1]
4. Watch for relapse. Treatment-related fluctuations occur within 8 weeks; deterioration after 8 weeks or three or more times should raise acute-onset CIDP.^[3]

Examiner questions

"Why are the reflexes still absent?" — decreased reflexes were present initially in 91 per cent of the Brighton cohort and in all during follow-up.^[5]

"He worsens again at month 3 — what now?" — beyond 8 weeks this is not a GBS treatment-related fluctuation; consider A-CIDP, which may need CIDP management.^[3][2]