A 6-year-old black male elementary school student was admitted to the pediatric ward on June 1, 2022, with a symptom of generalized body weakness (bilateral upper and lower extremity paralysis) 14 days earlier. The patient was given the inactivated poliovirus vaccine at the ages of two months, four months, 14 months, and eventually at the age of five years. Four weeks ago, the patient received the final inactivated poliovirus vaccination. He had no prior history of a fall, travel, urinary tract infections, bowel or urine incontinence, upper respiratory tract infections, or trauma. The patient had not provided any previous medical or medication histories. He had also no medical or medication histories in his family. He was in good health two weeks before his hospitalization and was attending school normally with no health issues.
Up on admission, he presented with generalized body weakness comprising both lower and upper extremities (unable to move legs and hands as a usual motor movement), not walking alone without caregiver assistance, being unable to swallow food, having eyesight problems, having tingling in the feet and hands, having an irregular heartbeat, and experiencing significant muscular discomfort. The patient had quadriparesis, or muscle weakness, in all four limbs (both legs and arms). His vital signs showed a heart rate of 98 beats per minute, a respiratory rate of 18 breaths per minute, a body temperature of 37.8 degrees celsius, and a saturation oxygen level of 96% on room air.
His physical examination revealed that his skin test, ear, lung, and abdominal examinations were all stable or normal. His cardiovascular, dermatologic, and respiratory systems were also normal. To assess the level of consciousness of patient the Glasgow Coma Scale, revealed eye opening reaction was 1/4 (no response), the motor response was 3/6 (abnormal flexion), and the verbal response was 2/5 (incomprehensible sounds). On a Glasgow Coma scale, his overall score was 6 (1/4 + 3/6 + 2/5). According to his Glasgow Coma Scale, he had severe brain damage and was comatose or partially unresponsive. His motor examination indicated reduced muscular strength in all limbs, with a Medical Research Council score of 2/5 in the right arm upper limbs and 1/5 in the right leg of the lower limbs, and 1/5 in the left leg of the lower extremities and 2/5 in the left arm of the upper limbs.
The assessment of the Erasmus Guillain Barré syndrome Respiratory Insufficiency Score revealed that the time lapse between the onset of weakness and the patient's hospital admission was greater than 7 days and scored as 0, facial and/or bulbar weakness at admission was absent and scored as 0, and the Medical Research Council sum score at admission was 34 out of 60 and scored as 2. This patient's Erasmus Guillain Barré Syndrome Respiratory Insufficiency Score was a perfect 2 (0 + 0 + 2). With a Respiratory Insufficiency Score of 0–2 for Erasmus Guillain Barré syndrome, this patient does not require mechanical ventilation.
The laboratory examination shown white blood cell count of 11,200 cells/mm3 (normal value: 4,500 − 11,000 cells/mm3), erythrocyte sedimentation rate of 54 mm/hour (normal value: 0–20 mm/hr), neutrophils of 73% (normal value: 55–70%), lymphocytes of 21% (normal value: 20–40%), serum glucose of 131 mg/dL (normal value: 70–110 mg/dL), serum creatinine of 0.5 mg/dL (normal value: 0.7–1.3 mg/dL), blood urea nitrogen of 33 mg/dL (normal value: 6–20 mg/dL), hemoglobin of 14.8 g/dL (normal value: 13.8–17.2 mg/dL), hematocrit of 43% (normal value: 41–50%), alanine aminotransferase of 42 units/L (normal value: 0–35 units/L), and aspartate aminotransferase of 50 units/L (normal value: 0–35 units/L). The cerebrospinal fluid examination revealed yellow fluid, albuminocytological dissociation with 1.43 g/L proteins, a normal cerebrospinal fluid/serum albumin ratio, and no oligoclonal bands. The presence of albumin-cytological separation supports the diagnosis of Guillain Barré syndrome.
When the patient was admitted, the physician prescribed dexamethasone 8 mg/ 2 ml intravenously twice daily for five days, but the pediatric specialist stopped after only he taken one injection because dexamethasone is not recommended for Guillain-Barre syndrome. On the same day, an oral suspension of ibuprofen 100 mg/5 ml was started, 10 ml three times a day for five days. After cerebrospinal fluid findings supported the diagnosis of Guillain Barré syndrome, he underwent intravenous immunoglobulin 400 mg/kg every day for five days. The patient's caregivers counseled as they made gentle massages, changed the patient’s position frequently, and moved upper and lower extremities commonly. He advised conducting motor stimulation exercises to restore muscle tone, as well as face mobility and paralysis training. The patient was advised not to climb ladders because they were afraid of falling and to avoid rigorous physical activities such as anerobic and aerobic sports.
Outcome and follow-up
After thirteen days of pharmacological and non-pharmacological treatment, he partially recovered from paralysis and started walking alone, slowly. The patient was admitted back home with marked improvement on July 16, 2022. His functional motor impairments upon discharge could be examined using the Guillain-Barre syndrome disability scale, and his Hughes disability score revealed that he had a grade 2 Hughes score (able to walk ten meters or more without assistance but unable to run).