A 32-year-old man from rural Maharashtra presents with a 5-day history of progressive weakness starting in both legs and ascending to involve the arms and face. He reports a diarrheal illness 2 weeks prior caused by Campylobacter jejuni. On examination, he has bilateral lower limb weakness (grade 3/5), areflexia, and intact sensation. Respiratory rate is 22/min. CSF analysis shows protein 85 mg/dL with normal cell count. What is the most appropriate immediate management?

Explanation

## Diagnosis and Clinical Reasoning **Key Point:** This patient presents with classic Guillain-Barré Syndrome (GBS) — acute ascending paralysis with areflexia, albuminocytologic dissociation on CSF, and recent Campylobacter infection (a known trigger). ## Management of GBS **High-Yield:** Both IVIG and plasmapheresis are first-line immunomodulatory therapies for GBS. IVIG is preferred in most centres because it is: - Easier to administer (peripheral IV access) - Safer in patients with renal impairment or volume overload - No need for vascular access (unlike plasmapheresis) - Equally effective when started within 2 weeks of symptom onset **Clinical Pearl:** The dose of IVIG in GBS is 2 g/kg total, typically given as 400 mg/kg daily for 5 days or 1 g/kg on days 1 and 2. Both regimens are equivalent. ## Timing and Respiratory Monitoring **Key Point:** Early intervention (within 2 weeks) reduces duration of mechanical ventilation and hospital stay. This patient is at day 5 of symptom onset — well within the therapeutic window. **Warning:** Although respiratory rate is currently 22/min (mildly elevated), forced vital capacity (FVC) and negative inspiratory force (NIF) must be monitored closely. Criteria for intubation include FVC <15 mL/kg, NIF >−30 cm H₂O, or rapid deterioration. ## Why Corticosteroids Are Not First-Line **High-Yield:** Corticosteroids alone do NOT improve outcomes in GBS and may worsen prognosis. Azathioprine has no role in acute GBS management. ```mermaid flowchart TD A[Suspected GBS: Ascending paralysis + areflexia + albuminocytologic dissociation]:::outcome --> B{Symptom onset < 2 weeks?}:::decision B -->|Yes| C[Start IVIG or Plasmapheresis]:::action C --> D[Monitor FVC, NIF, respiratory status]:::action D --> E{FVC < 15 mL/kg or NIF > -30?}:::decision E -->|Yes| F[Elective intubation]:::urgent E -->|No| G[Continue immunotherapy + supportive care]:::action B -->|No| H[Supportive care only]:::action ``` [cite:Harrison 21e Ch 379]