403 - A Case of unilateral facial palsy and bulbar weakness following a standard dose of IVIG in a Post-partum Patient with GBS

Case Diagnosis: 30-Year-Old Post-partum female with Guillain-Barre Syndrome, Unilateral Facial Palsy, and Bulbar weakness

Case Description: 30-year-old female who was 3 months Post-partum presented with ascending paresthesias and weakness. Symptoms began 24 hours prior with paresthesias in hands and feet but quickly progressed to lower extremity weakness and the inability to stand. Of note, the patient was diagnosed with bilateral ear infections 2 days prior and prescribed amoxicillin. Physical exam revealed decreased sensation and weakness, predominantly in her legs. Full laboratory workup was unremarkable. CT head was negative. MRI C-spine revealed intrathecal nerve root enhancement from C5-T1. MRI brain revealed subtle FLAIR hyperintensities on the right sided 7th cranial nerve and 5th cranial nerve entry zones. After the completion of IVIG the patient developed worsening unilateral facial palsy with bulbar weakness. Despite the new symptoms, lower extremity strength continued to improve. Neurology was urgently reconsulted and patient received an dose of IVIG with significant improvement.

Discussions: GBS patients with the inability to walk are generally treated with a standard single dose of IVIG 2g/kg bodyweight divided over 5 days. This single dose is insufficient in roughly a quarter of patients worldwide and in these cases an additional dose may be given. Although there is a paucity of data pointing to the efficacy of additional IVIG, it may prove beneficial in some cases.

Conclusions: In our patient, a single dose of IVIG was beneficial as she gained lower extremity strength and the ability to ambulate. However, with the new onset of facial palsy and bulbar weakness this patient required an additional dose of IVIG. This case points to the benefits of additional IVIG but more studies are required to show its overall effectiveness and safety on a larger scale.