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GUILLAIN- BARRE
SYNDROME
Minnie M. Chavez, M.D.
June 30, 2011
GRAND ROUNDS
Variable Leo Claire Dianne Kervin
Age/Sex 16/ M 14/F 12/F 2/M
Preceding infection
Respiratory
Respiratory
Respiratory
Respiratory
Quadriparesis
Yes Yes Yes Yes
Bulbar weakness
Yes Yes Yes Yes
Cranial neuropath
y
Yes Yes Yes Yes
Variable Leo Claire Dianne
Kervin
Nerve conduction
studies
AMANSevere motor denervation due to severe axonal dysfunction and demyelinating process
AMANDay 30: severe motor denervation RUE/RLE
AMSANDay 7: severe sensorimotor denervation all limbs; motor denervation was due to severe demyelinating and axonal dysfunction
AMANDay 6: severe motor denervation both upper & lower levels tested. SensoryPotential were relatively spared
OBJECTIVES1.To present an atypical
case of post - Rubeola GBS
2.To discuss the approach to diagnosis, differentials, immuno pathogenesis, clinical course and complications in the context of a multi-disciplinary management
GENERAL DATA
16 years oldMaleRight handedFilipinoRoman CatholicCagayan De OroApril 25, 2011
CHIEF COMPLAINT
Difficulty of breathing
HISTORY OF PRESENT ILLNESS
11 days
fever cough rash
pains numbness weakness
dyspnea
HISTORY OF PRESENT ILLNESS
fever cough rash
10 days
pains numbness weakness
dyspnea
HISTORY OF PRESENT ILLNESS
fever cough rash
7 days
pains numbness weakness
dyspnea
HISTORY OF PRESENT ILLNESS
fever cough rash
6 days
pains numbness weakness
dyspnea
HISTORY OF PRESENT ILLNESS
fever cough rash
pains
5 days
numbness weakness
dyspnea
HISTORY OF PRESENT ILLNESS
fever cough rash
pains numbness
4 days
weakness
dyspnea
HISTORY OF PRESENT ILLNESS
fever cough rash
pains numbness
3 days
weakness
dyspnea
HISTORY OF PRESENT ILLNESS
fever cough rash
pains numbness weakness
dyspnea
2 days
HISTORY OF PRESENT ILLNESS
fever cough rash
pains numbness
Day of Admission
weakness
dyspnea
FAMILY HISTORY
34
5670
192932
BIRTH AND MATERNAL HISTORYΘBorn to a 40 year old, G5P5
(5005)ΘNon-smoker, non-alcoholic
beverage drinker motherΘRegular prenatal check-ups
to a private obstetrician ΘNo maternal illnessΘNo intake of abortifacient
nor exposure to radiationΘFull term ΘNormal spontaneous
delivery ΘHospital in Cagayan De Oro
assisted by an obstetrician ΘNo fetomaternal
complications
NUTRITIONAL HISTORY
Θ Patient was breastfed for few days followed
by milk formulaΘ Regular diet consists of fried
fish, eggs and bread in breakfast, soup, rice and fish at lunch, and rice, fish and meat at dinner
Θ No food preference
IMMUNIZATION HISTORY
Θ BCGΘ DPT-OPV x 3 dosesΘ Hepatitis B x 3 dosesΘ MeaslesΘ MMR at 5 and 10
years oldΘ HiB Θ Varicella vaccines
GROWTH AND DEVELOPMENTAL HISTORY
Recalled developmental milestones were achieved at appropriate ages
HEADSSSΘH Patient is closer to his
mother. At home, he participates in household chores like washing the dishes and preparing meals
ΘE Presently, he is a 2nd year college student taking up Industrial Engineering in De La Salle University- Taft Avenue with three failed grades, however he claimed that his favorite subject is Science
HEADSSSΘA He enjoys playing soccer and other
outdoor physical activities like mountain climbingΘD He has no predilection to drugs nor to
dietingΘS At present, he has no relationship with
the opposite sex but admitted having a relationship in the past that lasted for 2 yearsΘS He has no suicidal ideationΘS He attends mass on Sundays
PAST MEDICAL HISTORY
Θ Diagnosed with Bronchial asthma
Θ No previous head traumaΘ No previous hospitalizationsΘ No allergies to food or drugs
PHYSICAL EXAMINATIONWeak looking, bed-borne, and in respiratory distress Vital Signs: BP 130/70 CR 160 bpm RR 41 bpmT 36.8 CWeight : 62.5 kg Height : 172. 7 cm BMI : 21 kg/m2 HC : 50 cmWarm to touch with generalized brawny desquamation and hyperpigmentation
PHYSICAL EXAMINATION Anicteric sclerae, hyperemic conjunctivae, no nasal discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathiesSymmetrical chest expansion, decreased breath sounds on the right with subcostal retractions and crackles on bilateral lung fieldsAdynamic precordium, apex beat at 5th left intercostal space mid-clavicular line, tachycardic, no murmursFlat abdomen, normoactive bowel sounds, soft, non-tender, no hepatosplenomegalyTight sphincteric tonePulses full and equal, no cyanosis nor edema
NEUROLOGICAL EXAMINATION
He is oriented to person, place and time .He has intact remote and recent memory. No agraphia, apraxia, dyscalculia, no left to right disorientationCranial Nerves:
I: intactII: Visual acuity 20/20, OU (Jaegers) ; no visual field cuts Fundoscopy: (+) ROR, clear media, AV ratio 2:3,
distinct disc margin, no retinal hemorrhages
II,III: pupils 2-3 mm equally reactive to light and accomodation
III, IV, VI: Extra ocular muscles full and equalV: good temporalis and masseter tone; V1-V3 intactVII: unable to raise eyebrows and wrinkle forehead, unable
to completely close both eyelids, unable to smile, unable to puff air into the cheeks
VIII: gross hearing intactIX, X: weak gag reflex, bilateral; dysphagia with pooling of
saliva (+) hoarse voice with dysphonia
XI: turns head to both sides against resistance; good shoulder shrug
XII: tongue midline on protrusion
NEUROLOGICAL EXAMINATION
Motor Exam: A. Strength
Manual Muscle Testing (MMT)
Right Left
Arm elevation 3/5 3/5
Arm adduction downward
3/5 3/5
Arm adduction across the chest
3/5 3/5
Arm abduction 3/5 3/5
Scapula adduction 3/5 3/5
Elbow flexion 3/5 3/5Elbow extension 3/5 3/5
Wrist Flexion 3/5 3/5Wrist Extension 3/5 3/5
Manual Muscle Testing (MMT)
Right Left
Finger Abduction 3/5 3/5Finger adduction 3/5 3/5Finger extension 3/5 3/5Finger flexion 3/5 3/5Hip flexion 2/5 2/5Thigh abduction 2/5 2/5Thigh adduction 2/5 2/5Hip extension 2/5 2/5Knee extension 2/5 2/5Knee flexion 2/5 2/5Foot dorsiflexion 2/5 2/5Foot inversion 2/5 2/5Foot eversion 2/5 2/5Plantar flexion 2/5 2/5Toe flexion 2/5 2/5Toe extension 2/5 2/5
NEUROLOGICAL EXAMINATION
B. Tone – symmetrically hypotonic in all extremitiesC. Absence of atrophy/BulkD. No muscle tenderness/ pain on palpationE. No involuntary involvementsSensory: intact pain and temperature, position and vibration, light touch, 2-point discriminationCerebellar: Because of the weakness patient was unable to do FTNT, tandem walking and other cerebellar function testsDeep Tendon Reflexes Right Left
Biceps (C5, C6) +1 +1Brachioradialis (C5, C6) +1 +1
Triceps (C6, C7, C8) +1 +1
Patellar (L2, L3, L4) 0 0
Achilles Tendon (S1, L5) 0 0
No extensor toe sign, no clonusMeningeals: no nuchal rigidity
2+
Salient Features
Θ 16 year old male, right handedΘ Preceded by a 10 day history of a systemic
viral illness Θ Low back pains and paresthesias in the
toesΘ Acute ascending symmetric motor
weaknessΘ Normal mental statusΘ Facial diplegia, hoarseness, decreased
muscle strength, hypo/areflexia, no extensor toe sign
2+
2+
Approach to Diagnosis
Is there a disease in the
nervous system?
Yes
2+
Levelize the LesionCerebral cortex
Cerebellum
Brainstem
Spinal Cord
2+
Levelize the Lesion
Motor Neurons• Amyotrophic Lateral Sclerosis
Muscle Fibers• Myotonic Dystrophy
Neuromuscular Junctions• Myasthenia Gravis
Peripheral Nerve• Guillain-Barre Syndrome
2+
LocalizATIONUpper Motor
Neuron
Hyperactive
Absent
Absent
Increased
Positive
Lower Motor
Neuron
Absent
Present
Present
Decreased
Negative
Reflexes
Atrophy
Fasciculations
Tone
Babinski
Patient
Absent
Absent
Absent
Decreased
Negative
THE PERIPHERAL NERVE
Which part of the peripheral nervOUS
SYSTEM?
• Anterior horn cell x
• Neuromuscular junction x
• Muscle x
Roots
Nerve
PERIPHERAL NERvous system
2+
What is the etiology?
Infectious
Toxic Vascular
Traumatic
Neoplastic
Metabolic Genetic
Post-infectious
AUTOIMMUNE
Peripheral nerve disorders
Polyneuropathy
Mononeuropath
y
Mono neuritis complex
CLASSIFICATION OF POLYNEUROPATHIES
TYPES OF FIBERS
INVOLVED
PATHOLOGY
TEMPO
DIFFERENT DISEASES WITH polyneuropathies
ΘFatigue
ΘDelayed DTRs
ΘSlow movement and speech
ΘCold intolerance
ΘConstipation and weight gain
HYPOTHYROIDISM
ΘDistal to proximal involvement
ΘSlowly progressive (over months) abnormalities in sensory, motor, autonomic, and gait function
Θ No history of chronic alcohol use with nutritional deficits
ALCOHOLIC NEUROPATHY
TOXIC NEUROPATHY
ΘDrug abuse and exposure to chemicals
ΘDistal > proximal
ΘPains
METAL NEUROPATHY
2+
immunopathology
Spinal nerve roots
Distal nerve segments
Around potential nerve entrapment sites
Lymphocyte attach to the endoneural
vessels
Lymphocyte migration and breakdown of
myelin
Interruption of the axon, polymorphonuclear
leukocytes
Denervation atrophy of muscle
IMMUNOPATHOGENESIS
TRIGGERS
50% 32%
Upper Respiratory Tract InfectionCytomegalovirusEpstein-Barr VirusGastro-intestinal Tract InfectionCampylobacter jejuni
Vaccination, Malignancies, Bone marrow transplantation, surgeries
2+
ImmunoPathogen
• A process wherein exogenous antigens have structural appearance to self-antigens
• The host generates an immune response to the inciting factor (usually an infectious organism) that shares epitopes with host’s affected tissue
MOLECULAR MIMICRY
CELLULAR AND HUMORAL IMMUNITY
COMPLEMENT SYSTEM
2+
Working Impression
Acute post- Rubeola poly radiculoneuropathy (Guillain-Barre Syndrome) with impending respiratory failure
HISTORICAL BACKGROUND
Θ Landry's ascending paralysis, French
polio, acute idiopathic polyneuritis, or acute idiopathic polyradiculoneuritis
Θ French physician Jean Landry had
described the condition in 1859
Θ Named for Georges Guillain and Jean Alexandre Barre: increased level of protein with normal cell count in cerebrospinal fluid (1916)
DEFINITION
An acute, immune-mediated disorder of peripheral nerves, spinal roots, and cranial nerves, commonly presenting as a rapidly progressive, areflexive, relatively symmetric ascending weakness of the limb, truncal, respiratory, pharyngeal, and facial musculature, with variable sensory and autonomic dysfunction
What’s new in Guillain-Barré syndrome? J Pritchard; Dr Jane Pritchard, Neurology Specialist Registrar, The National Hospital for Neurology and Neurosurgery, Queen Square, London; WC1N 3BG, UK; [email protected]
DIAGNOSTIC CRITERIAFeatures required for diagnosis
Progressive weakness in both arms and legsAreflexia
Features strongly supporting diagnosisProgression of symptoms over days, up to four weeksRelative symmetry of symptomsMild sensory symptoms or signsCranial nerve involvement, especially bilateral weakness of facial musclesRecovery beginning two to four weeks after progression ceasesAutonomic dysfunctionAbsence of fever at onsetHigh concentration of protein in cerebrospinal fluid, with fewer than 10 cells per cubic millimeterTypical electrodiagnostic features
Features excluding diagnosisDiagnosis of botulism, myasthenia, poliomyelitis, or toxic neuropathyAbnormal porphyrin metabolismRecent diphtheriaPurely sensory syndrome, without weakness
Annual incidence globally is 0.5 - 1.5 cases per 100,000 population per year < 18 years old. Youngest recorded patient: 2 years old,male predominance. Axonal type in Asians.
From the Philippine Pediatric Society Registry: 168 GBS patients have been reported from a total of 992, 341 cases
From the Philippine Children’s Medical Center: 120 patients have been seen from 1995 to June 2011
Source: Pediatric Guillain-Barre Syndrome Author: Sameer Chhibber, MD, FRCPC; Chief Editor: Amy Kao, MD
www.pps.org/ Registry.
Philippine Children’s Medical Center – Medical Records Section
GLOBAL AND LOCAL Incidence
2+
Clinical Manifestations
WeaknessReduced or absent reflexesSensory disturbancePainCranial nerve involvementRespiratory dysfunctionsDysautonomia
TWO Pathologic classificationS
Demyelinating
Axonal
AIDP
MFS BBE
PCB
Sensory
AMSAN
AMANAutonomic
FD
SPECTRUM OF GBS 2010
JB Winter/ Journal of Immunology 231 (2011)
variantsAcute Motor and Sensory
Axonal Neuropathy
Acute Motor Axonal Neuropathy
Miller Fischer Variant
Pure Motor Variants
Pure Sensory Variants
Pure Dysautonomia Variant
Pharyngeal-Cervical-Brachial Variant
Paraparetic Variant
Less Common variants
ELECTROPHYSIOLOGICAL CRITERIA
Atleast one of the following in each of atleast 2 nerves, or atleast two of the following in one nerve if all others
inexcitable and dCMAP > 10% LLN: Motor conduction velocity < 90% LLN (85% if dCMAP < 50% LLN); Distal motor latency >
110% ULN (> 120% if dCMAP < 100% LLN) pCMAP/dCMAP ratio < 0.5 and dCMAP > 20% LLN, F response latency > 120% ULN
None of the features of AIDP except one demyelinating feature allowed in one nerve
if dCMAP < 10% LLN, sensory action potentials amplitudes < LLN
None of the features of AIDP except one demyelinating feature allowed in one nerve if dCMAP < 10% LLN, sensory action potentials
amplitudes normal
AIDP
AMSAN
AMAN
Classification of GBS syndrome and related disorders
Typical antiganglioside antibodies by pathology
Acute inflammatory demyelinating polyradiculoneuropathy (AIDP)
Unknown
Acute motor and sensory axonal neuropathy (AMSAN)
GM1,GM1b,GD1a
Acute motor axonal neuropathy (AMAN) GM1,GM1b,GD1a, GaINac-GD1a
Acute sensory axonal neuropathy GD1b
Acute pandysautonomia Regional variants Fisher’s syndrome Oropharyngeal
GQ1b,GT1aGT1a
Overlap Fisher’s syndrome/ GBS overlap syndrome
GQ1b,GMi, Gmib, GD1a, GaINac-GD1a
Θ Multifocal mononuclear cells infiltration throughout the peripheral nervous system in which the distribution of inflammation corresponds to the clinical deficit
Θ Macrophages invade the myelin sheaths and denude the axons
AIDPAcute Inflammatory Demyelinating
Polyneuropathy
ΘActivation of anti-GQ1b and anti-GT1a antibodies that target oculomotor and bulbar nerves
ΘThe presynaptic nerve terminal axons and perisynaptic Schwann cells are damaged
FISHER’S SYNDROME
ΘThe pathology resembles that in AMAN, with the same pattern of macrophage invasion of the perinodal space
ΘThe dorsal, as well as the ventral, roots are affected
ΘThere is the same paucity of lymphocytic inflammation consistent with an antibody-mediated pathogenesis
AmSanAcute Motor Sensory Axonal Neuropathy
Θ Macrophages invade the nodes of Ranvier, where they insert between the axon and the surrounding Schwann cell axolemma, leaving the myelin sheath intact
Θ Severe: axons are damaged in the ventral root, which may cause severe degeneration of the whole axon
AmanAcute Motor Axonal Neuropathy
Course in the ICU
ADMISSION
CBC
Hgb 156
Hct 0.46
WBC 17.7
Seg 0.92
Lym 0.02
Mono 0.06
Platelet 494
ABG
pH 7.4
pC02 39
p02 70
HC03 24.2
02 sat
BE -0.5
Θ Is the most common serious complication of Guillain-Barre syndrome
Θ Acute Respiratory Failure:1. Alveolar-arterial oxygen gradient of
300mm Hg with an inspired oxygen fraction of 1.0
2. Arterial PC02 above 45mm Hg3. Static inspiratory pressures below 30
cm H20
Mechanical failure of the thoracic bellows is the problem
Θ Intubation criteria 1. Mechanical ventilator failure with
reduced expiratory VC of 12-15 ml/kg2. P02 below 70 mm Hg with inspired room
air3. Severe oropharyngeal paresis with
difficulty clearing secretions or repeated coughing and aspiration after swallowing
Θ Mortality rate was 3% for all patients who could not walk and zero for those who required mechanical ventilation directly as a result of GBS
Θ Complications of tracheostomy in GBS: 7-55%
2+
investigations
LUMBAR PUNCTURE AND CSF ANALYSIS
Θ Before treatment because IVIG can cause aseptic meningitis
Θ WBC < 10 x 10 cells/ L
Θ Raised protein but normal in the first weekWhat’s new in Guillain-Barré syndrome? J Pritchard; Dr Jane Pritchard, Neurology
Specialist Registrar, The National Hospital for Neurology and Neurosurgery, Queen Square, London; WC1N 3BG, UK; [email protected]
IMMUNO THERAPY
The main modalities of therapy: Θ Intravenous immune
globulinΘ Plasmapheresis
Plasma Exchange
IVIg Combined
Treatments
Corticosteroid
s
Strong evidence supports
PE recommended in nonambulant patients within 4 weeks of onset of neuropathic symptoms(Level A*, Class II**)
IVIG recommended in non ambulant patients within 2 weeks of onset of neuropathic symptoms(Level A, Class II)
Sequential treatment with PE followed by IVIG does not have a greater effect than either treatment given alone (Level A, Class I)
Steroids not recommended in the treatment of GBS (Level A, Class I)
EVIDENCE FOR IMMUNOTHERAPY
2003 Practice Parameter Quality Standards Subcommittee of the American Academy of Neurology
2+
PLASMAPHERESIS
2+
PLASMAPHERESIS
Course in the ICU
2nd – 5th Hospital Day
WEANING
Villaure, Wilson. Guillain-Barré syndrome: Treatment and Prognosis Version 7. Knol. 2009 Feb 8. Available from: http://knol.google.com/k/wilson-villaure/guillain-barré-syndrome/1bbsle13m97c0/127.
Θ Improvement in strength
Θ Serial Pulmonary function tests
Θ Tracheostomy
Θ The autonomic neuropathy involves both the sympathetic and parasympathetic systems
Θ Manifestations: alternating hypotension with hypertension, urinary retention, sweating abnormalities, and sinus tachycardia
Villaure, Wilson. Guillain-Barré syndrome: Treatment and Prognosis Version 7. Knol. 2009 Feb 8. Available from: http://knol.google.com/k/wilson-villaure/guillain-barré-syndrome/1bbsle13m97c0/127.
ACUTE PHASE REHABILITATION
Orsini, M., de Freitas M., Presto, M. Guidelines for Neuromuscular Rehabilitation In Guillain-Barre Syndrome: What can we do ? Rev Neuroscience 2010; 18: 4: 572-580
Course in the ICU
6th - 7th Hospital Day
Thyroid function tests
Free T3 < 0.05 (1.4-4.2)
Free T4 2.135 (0.8-2 ng/dl)
TSH 0.208 uIU/ml(0.4-7
uIU/ml)
Peeters RP, van der Geyten S, Wouters PJ, Darras et al Tissue thyroid hormone levels in critical illness. Journal of Clinical Endocrinology and Metabolism. 90: 6498-6507. 2005
TSH T4 T3 Interpretation
High Normal Normal Mild (subclinical) hypothyroidism
High Low Low or normal Hypothyroidism
Low Normal Normal Mild (subclinical) hyperthyroidism
Low High or normal
High or normal
Hyperthyroidism
Low Low or normal
Low or normal Nonthyroidal illness; rare pituitary (secondary) hypothyroidism
NON THYROIDAL ILLNESS SYNDROME
Peeters RP, van der Geyten S, Wouters PJ, Darras et al Tissue thyroid hormone levels in critical illness. Journal of Clinical Endocrinology and Metabolism. 90: 6498-6507. 2005
Course in the ICU
8th - 9th Hospital Day
SIADH
Θ 1/3rd of patientsΘ Rarely symptomaticΘ In ventilated patients: 42% versus 19%Θ Average occurrence: 10 days after intubation (range 1-23 days)Θ Resolved after fluid restrictionΘ Downward osmotic resetting and enhanced renal sensitivity to ADH
2+
NeurophysiologyNCVAmplitudes of sensory nerve action potentials (SNAPs) evoked on antidromic stimulation of the left median, left ulnar, left radial, right and left (bilateral) sural nerves were normal. Distal sensory latencies were normal.Sensory nerve conduction velocities(NCVs) were normal.
No compound muscle action potentials (CMAPs) were evoked on proximal stimulation of right peroneal tibial nerve. Amplitude of the CMAPs evoked on stimulation of the left medial, left ulnar and bilateral peroneal nerves were severely reduced. Temporal dispersion was appreciated Motor latencies were generally prolongedMotor NCVs of the left median and left ulnar and right peroneal nerves were normal. Distal and proximal motor NCVs of the left peroneal nerve were normal and mildly slowed, respectively. Motor NCV of the left tibial nerve was mildly slowed
Course in the ICU
10th - 12th Hospital Day
Plasma Renin
132.5 pg/ml
Supine: 1.1-20 pg/ml
Upright: 1.8-60 pg/ml.
PLASMA RENIN
ELEVATED LIVER FUNCTION TESTS
ELEVATED LIVER FUNCTION TESTS
Liver function disturbances in Guillain-Barre syndrome. A prospective longitudinal study in 100 patients P. G. Oomes, MD, F.G.A. van der Meche, MD, PhD and R. P. Kleyweg, MD, PhD
Θ 100 patients with Guillain-Barre syndromeΘ On admission, 38% showed an increase SGPT ..10% had
serologic evidence of recent cytomegalovirus infection. The remaining 28 patients were negative for other known causes of liver damage
Θ In the IVIg-treated group, 35% before to 69% shortly after treatment
Θ In the PE-treated group, 41% to 36%
Conclusion: Θ GBS patients had mild liver function disturbances
without obvious cause Θ IVIg was associated with mild transient liver
function disturbances through an unknown mechanism
Course in the ICU
13th -16th Hospital Day
Course in the ICU
17th- 23rd Hospital Day
Course in the ICU
24th – 26th Hospital Day
Course in the ICU
27th- 30th Hospital Day
2+
Treatment SUMMARY
Supportive care
Ventilatory support
Autonomic dysfunction
Nosocomial infections
Venous thrombosis
Nutritional support
Immune therapy
SUPPORTIVE CARE
Prophylaxis for deep vein
thrombosis
Bowel and bladder
care
Physical and
occupational
therapy
Psychosocial
support
2+
prognosis
Mortality rates range from 2 to 13%
Most common causes of death after GBS: respiratory failurecardiovascular and autonomic disturbancesthrombo-embolisms
15% have mild illness, remain ambulatory, and recovery after few weeks5-20% have fulminant course
low mean Compound Muscle Action Potential Amplitude (CMAP) - the most powerful predictor of poor recovery rate
Guideline for Neuromuscular Rehabilitation in Guillain-Barré Syndrome: What can we do? Marco Orsini, Marcos RG de Freitas, Bruno Presto, Rev Neurocienc 2010;18(4):572-580
Θ MonophasicΘ 10% - early
relapse in 1st week or two following treatment
Θ 3% - subsequent years
Θ CIDP
What’s new in Guillain-Barré syndrome? J Pritchard; Dr Jane Pritchard, Neurology Specialist Registrar, The National Hospital for Neurology and Neurosurgery, Queen Square, London; WC1N 3BG, UK; [email protected]
recurrence
2+
Final Diagnosis
Post-Rubeola Guillain-Barre Syndrome with respiratory failure, resolvedSecondary HypertensionSecondary HypothyroidismExposure Keratitis, OU
Follow-up
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