A 28-year-old woman with confirmed GBS (positive anti-GQ1b antibodies, demyelinating features on NCS) is 5 days into illness with moderate weakness of all four limbs and intact respiratory function (vital capacity 85% predicted). She is hemodynamically stable. Which is the most appropriate next step in management?

Explanation

## Clinical Context This patient has confirmed GBS with moderate disability, stable respiratory function, and is within the therapeutic window (5 days from onset). Both IVIG and plasmapheresis are equally effective, but IVIG is preferred as first-line in most settings due to ease of administration and availability. ## Why IVIG is the Correct Next Step **Key Point:** Immunotherapy should be initiated within 2 weeks of symptom onset in GBS. Earlier treatment (within first week) is associated with better outcomes and faster recovery. **High-Yield:** IVIG vs. Plasmapheresis — Evidence-Based Comparison: | Feature | IVIG | Plasmapheresis | |---------|------|----------------| | **Efficacy** | Equivalent | Equivalent | | **Onset** | 3–5 days | 1–3 days (faster) | | **Ease of access** | Easier in India | Requires apheresis unit | | **Contraindications** | IgA deficiency, thrombosis risk | Hemodynamic instability, sepsis | | **Cost** | Higher | Lower | | **First-line** | Yes (most centers) | Alternative if IVIG unavailable | **Clinical Pearl:** The patient is at day 5 — still within the optimal window. Delaying immunotherapy increases disability at 4 weeks and prolongs recovery. ## GBS Management Algorithm ```mermaid flowchart TD A[GBS diagnosis confirmed]:::outcome --> B{Days from onset?}:::decision B -->|<14 days| C{Respiratory compromise?}:::decision B -->|>14 days| D[Supportive care only]:::action C -->|No, VC >70%| E[Start immunotherapy]:::action C -->|Yes, VC <70%| F[ICU + respiratory support first]:::urgent E --> G{IVIG or Plasmapheresis?}:::decision G -->|IVIG available| H[IVIG 2 g/kg over 5 days]:::action G -->|Plasmapheresis available| I[5 exchanges over 7–10 days]:::action F --> J[Stabilize, then start immunotherapy]:::action ``` **Mnemonic:** **IVIG-GBS** — Intravenous Immunoglobulin is the standard first-line in GBS (most centers in India). **Warning:** Corticosteroids alone are ineffective and may worsen GBS — do NOT use as monotherapy. Observation without immunotherapy leads to prolonged disability.