Bilateral Facial Palsy and Hyperreflexia as the Main Clinical Presentation in Guillain-Barré Syndrome

Patient: Male, 37-year-old Final Diagnosis: Guillain-Barré syndrome Symptoms: Facial paralysis • paresthesia Medication: — Clinical Procedure: Cerebrospinal fluid analysis • magnetic resonance image • nerve conduction study Specialty: Neurology OBJECTIVE: Unusual clinical course BACKGROUND: Guillain-Barré syndrome (GBS) is an autoimmune disease of the peripheral nervous system. It has multiple presentations, demyelinating or axonal, according to the pattern of injury. In general, there are cardinal symptoms, such as areflexia and ascending symmetrical lower limb weakness. GBS has multiple different variants. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) is the most common type. Other known variants are acute motor and sensory axonal neuropathy, acute motor axonal neuropathy, acute sensory neuropathy, acute pan dysautonomia, and Miller Fisher syndrome. CASE REPORT: In the present case, the patient had initial symptoms of distal bilateral paresthesia and 12 days later he developed left facial muscle weakness, a decrease in ability to taste, and right facial muscle weakness. Two days later the patient said he did not have limb weakness. On examination, he had bilateral lower motor facial palsy, the power in his upper and lower right limbs was 4/5, and he had bilateral upper limb hyperreflexia. Results of a nerve conduction study were consistent with acute demyelinating polyneuropathy with secondary axonal loss. The patient was treated with immunoglobulin G, 0.4 mg/kg/d for 5 days, and fully recovered. CONCLUSIONS: Facial diplegia is one of the GBS variants that presents rarely as pure bilateral facial weakness or is preceded by bilateral lower limb weakness. The present case underscores that patients with GBS may have facial diplegia before weakness. Also, they may not have areflexia as a cardinal feature, and instead, hyperreflexia may be seen. Although hyperreflexia has been reported in association with the acute motor axonal variant, the present case shows that hyperreflexia also can be found with AIDP.