GUILLAIN-BARRÉ SYNDROME (GBS) is an acute polyneuropathy in which the peripheral nervous system is damaged. Although most patients reportedly fully recover or show only mild residual symptoms, a more recent study indicated that a considerable number of patients mentioned a change in psychological conditions including anxiety, insomnia, and impaired concentration.1 Some patients experienced depression.1 Thus, an accurate prognosis of GBS would be important, so that early introduction of psychological support may be beneficial for prevention of post-disease depression when recovery is poor. A certain type of antecedent agent has been identified as an important prognostic indicator.2 A previous study suggested that antecedent infection by Haemophilus influenzae could be an indicator of rapid clinical recovery, whereas infection by Campylobacter jejuni is an indicator of poor prognosis.2 We here describe a patient with GBS subsequent to H. influenzae infection who experienced poor recovery and depression.
A 65-year-old man developed limb weakness 1 week after pneumonia and was hospitalized (day 1). He previously had not had diarrhea, nor did he have any past history of psychiatric disorders. The patient required mechanical ventilation on day 2. Haemophilus influenzae (non-typable, biotype III) was isolated (>107/mL) from his purulent sputum. An enzyme-linked immunosorbent assay on day 2 showed high anti-GM1, anti-GM1b, and anti-GD1a IgG antibody titers (32 000, 8000, and 2000, respectively; normal, <500). Anti-cytomegalovirus IgM, anti-C. jejuni and anti-Mycoplasma pneumoniae antibodies were all negative. A nerve conduction study on day 7 showed that none of the motor and sensory nerves in the four limbs were excitable. Despite treatment with plasmapheresis and i.v. immunoglobulin, tetraplegia persisted for more than 1 year. Although the mechanical respirator was no longer needed on day 17, the patient started to suffer from insomnia, general fatigue and appetite loss. He also complained about strong anxiety and loss of motivation, which prompted him to discontinue rehabilitation. Psychopharmacotherapy including selective serotonin re-uptake inhibitor was introduced but depressive symptoms persisted for several months. Continuous psychological support was necessary during the 6-month hospitalization period and the patient's wife also suffered from insomnia and anxiety, which needed psychiatric treatment as well.
Unlike those previously reported,2,3 the present patient's most striking features were his severe symptoms and poor outcome. The present case suggests that H. influenzae-related GBS does not always follow a benign clinical course and that fulminant GBS may need as much careful attention as cerebrovascular diseases with regard to post-disease depression.