Letter Vision Loss in Guillain‑Barre Syndrome; a Complication or a Coincidence Mahmood Dhahir Al‑Mendalawi, MB, CH.B, DCH, FICMS Department of Pediatrics, Al‑Kindy College of Medicine, Baghdad University, Baghdad, Iraq
J Ophthalmic Vis Res 2017; 12(1): 124‑125
Dear Editor, In their interesting case report, Ramakrishan et al described a patient with Guillain‑Barre syndrome (GBS) who developed vision loss during the course of the illness and proved later to have posterior reversible encephalopathy syndrome (PRES). [1] Herein, the following two comments regarding that case report can be made. First, PRES is a clinical condition characterized by sudden systemic hypertension associated with headache, seizure, visual disturbance, and altered mental state. The authors mentioned that GBS with dysautonomia can be considered as an independent risk factor for the development of various clinical manifestations of PRES (such as visual disturbance) through which an acute increase in blood pressure results in the release of pro‑inflammatory cytokines to break the blood‑brain barrier and cause vasogenic edema. [1] Such explanation cannot be applied to the current case as the patient had no documented persistent hypertension. Actually, the association of PRES without arterial hypertension with autoimmune‑mediated inflammatory neuropathies such as GBS is a rare and poorly understood phenomenon. There might be another mechanism contributing to the development of PRES in this GBS patient. The authors mentioned that the patient received intravenous immunoglobulin (IVIG) 20 g/day for 5 days. On day 14 after admission, the patient had two attacks of generalized seizures to be associated later with severe vision loss in both eyes.[1] To date,
various reports have described PRES as an adverse event subsequent to immunomodulatory treatment with IVIG in cases of axonal and demyelinating GBS.[2‑4] The exact mechanism is not fully understood. Hence, in severe GBS cases, immunoadsorption has been advocated as the first‑line therapy instead of IVIG for rapid removal of IgG to hasten recovery, improve functional outcome, and minimize serious aftermaths.[4] Second, the authors stated that PRES can occur concurrently with weakness or during the course of GBS.[1] It should be noted that PRES preceding the development of GBS has previously been reported.[5]
Financial Support and Sponsorship Nil.
Conflicts of Interest There are no conflicts of interest.
REFERENCES 1.
2.
3.
Correspondence to:
Mahmood Dhahir Al‑Mendalawi, MB, CH.B, DCH, FICMS. Department of Pediatrics, Al‑Kindy College of Medicine, Baghdad University, Baghdad Post Office 55302, Iraq. E‑mail: [email protected] Received: 14‑08‑2016
124
Accepted: 09‑12‑2016
4.
5.
Ramakrishnan S, Kannan B, Kannan A, Venkatesan EP. Vision loss in Guillain‑Barre syndrome: Is it a complication of Guillain‑Barre syndrome or just a coincidence? J Ophthalmic Vis Res 2016;11:340‑341. Doss‑Esper CE, Singhal AB, Smith MS, Henderson GV. R e v e rs i b l e p o s t e ri o r l e u k o e n ce p h a l o p a t h y , cer eb r al vasoconstriction, and strokes after intravenous immune globulin therapy in guillain‑barre syndrome. J Neuroimaging 2005;15:188‑192. Koichihara R, Hamano S, Yamashita S, Tanaka M. Posterior reversible encephalopathy syndrome associated with IVIG in a patient with Guillain‑Barré syndrome. Pediatr Neurol 2008;39:123‑125. Stetefeld HR, Lehmann HC, Fink GR, Burghaus L. Posterior reversible encephalopathy syndrome and stroke after intravenous immunoglobulin treatment in Miller‑Fisher syndrome/Bickerstaff brain stem encephalitis overlap syndrome. J Stroke Cerebrovasc Dis 2014;23:e423‑e425. Rigamonti A, Basso F, Scaccabarozzi C, Lauria G. Posterior
© 2017 Journal of Ophthalmic and Vision Research | Published by Wolters Kluwer - Medknow
Letter; Al‑Mendalawi reversible encephalopathy syndrome as the initial manifestation of Guillain‑Barré syndrome: Case report and review of the literature. J Peripher Nerv Syst 2012;17:356‑360.
Access this article online Quick Response Code:
Website: www.jovr.org
DOI: 10.4103/2008-322X.200160
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Al-Mendalawi MD. Vision loss in guillain-barre syndrome; a complication or a coincidence. J Ophthalmic Vis Res 2017;12:124-5.
Journal of Ophthalmic and Vision Research Volume. 12, Issue. 1, January-March 2017
125
J Ophthalmic Vis Res 2017; 12(1): 124‑125
Dear Editor, In their interesting case report, Ramakrishan et al described a patient with Guillain‑Barre syndrome (GBS) who developed vision loss during the course of the illness and proved later to have posterior reversible encephalopathy syndrome (PRES). [1] Herein, the following two comments regarding that case report can be made. First, PRES is a clinical condition characterized by sudden systemic hypertension associated with headache, seizure, visual disturbance, and altered mental state. The authors mentioned that GBS with dysautonomia can be considered as an independent risk factor for the development of various clinical manifestations of PRES (such as visual disturbance) through which an acute increase in blood pressure results in the release of pro‑inflammatory cytokines to break the blood‑brain barrier and cause vasogenic edema. [1] Such explanation cannot be applied to the current case as the patient had no documented persistent hypertension. Actually, the association of PRES without arterial hypertension with autoimmune‑mediated inflammatory neuropathies such as GBS is a rare and poorly understood phenomenon. There might be another mechanism contributing to the development of PRES in this GBS patient. The authors mentioned that the patient received intravenous immunoglobulin (IVIG) 20 g/day for 5 days. On day 14 after admission, the patient had two attacks of generalized seizures to be associated later with severe vision loss in both eyes.[1] To date,
various reports have described PRES as an adverse event subsequent to immunomodulatory treatment with IVIG in cases of axonal and demyelinating GBS.[2‑4] The exact mechanism is not fully understood. Hence, in severe GBS cases, immunoadsorption has been advocated as the first‑line therapy instead of IVIG for rapid removal of IgG to hasten recovery, improve functional outcome, and minimize serious aftermaths.[4] Second, the authors stated that PRES can occur concurrently with weakness or during the course of GBS.[1] It should be noted that PRES preceding the development of GBS has previously been reported.[5]
Financial Support and Sponsorship Nil.
Conflicts of Interest There are no conflicts of interest.
REFERENCES 1.
2.
3.
Correspondence to:
Mahmood Dhahir Al‑Mendalawi, MB, CH.B, DCH, FICMS. Department of Pediatrics, Al‑Kindy College of Medicine, Baghdad University, Baghdad Post Office 55302, Iraq. E‑mail: [email protected] Received: 14‑08‑2016
124
Accepted: 09‑12‑2016
4.
5.
Ramakrishnan S, Kannan B, Kannan A, Venkatesan EP. Vision loss in Guillain‑Barre syndrome: Is it a complication of Guillain‑Barre syndrome or just a coincidence? J Ophthalmic Vis Res 2016;11:340‑341. Doss‑Esper CE, Singhal AB, Smith MS, Henderson GV. R e v e rs i b l e p o s t e ri o r l e u k o e n ce p h a l o p a t h y , cer eb r al vasoconstriction, and strokes after intravenous immune globulin therapy in guillain‑barre syndrome. J Neuroimaging 2005;15:188‑192. Koichihara R, Hamano S, Yamashita S, Tanaka M. Posterior reversible encephalopathy syndrome associated with IVIG in a patient with Guillain‑Barré syndrome. Pediatr Neurol 2008;39:123‑125. Stetefeld HR, Lehmann HC, Fink GR, Burghaus L. Posterior reversible encephalopathy syndrome and stroke after intravenous immunoglobulin treatment in Miller‑Fisher syndrome/Bickerstaff brain stem encephalitis overlap syndrome. J Stroke Cerebrovasc Dis 2014;23:e423‑e425. Rigamonti A, Basso F, Scaccabarozzi C, Lauria G. Posterior
© 2017 Journal of Ophthalmic and Vision Research | Published by Wolters Kluwer - Medknow
Letter; Al‑Mendalawi reversible encephalopathy syndrome as the initial manifestation of Guillain‑Barré syndrome: Case report and review of the literature. J Peripher Nerv Syst 2012;17:356‑360.
Access this article online Quick Response Code:
Website: www.jovr.org
DOI: 10.4103/2008-322X.200160
This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Al-Mendalawi MD. Vision loss in guillain-barre syndrome; a complication or a coincidence. J Ophthalmic Vis Res 2017;12:124-5.
Journal of Ophthalmic and Vision Research Volume. 12, Issue. 1, January-March 2017
125
