Open Access Case

Report DOI: 10.7759/cureus.64432

Management of Severe Pain in a Case of Sensory

Guillain-Barre Syndrome
Review began 07/03/2024
Joane Titus 1 , Bernard Sarmiento 2, Roger Crouse 3
Review ended 07/08/2024
Published 07/12/2024 1. Medicine, University of Central Florida College of Medicine, Orlando, USA 2. Neurology, University of Central Florida
© Copyright 2024 College of Medicine, Orlando, USA 3. Internal Medicine, University of Central Florida Hospital Corporation of America
Titus et al. This is an open access article (HCA) Healthcare Graduate Medical Education (GME), Orlando, USA
distributed under the terms of the Creative
Commons Attribution License CC-BY 4.0.,
Corresponding author: Joane Titus, joanetitus92@gmail.com
which permits unrestricted use, distribution,
and reproduction in any medium, provided
the original author and source are credited.

Abstract
Guillain-Barre syndrome (GBS) is an acute post-infectious polyradiculoneuropathy characterized by
autoantibodies targeting host antigens, resulting in nerve fiber demyelination and axonal degeneration.
While symmetric ascending weakness is typical, neuropathic pain is a common yet variable manifestation.
We present a case of a 52-year-old man with progressive bilateral leg weakness and severe neuropathic pain
following a flu-like illness. Despite conventional analgesics, his pain persisted, necessitating a unique pain
management approach.

The patient's examination revealed hyporeflexia and sensory deficits consistent with GBS. Diagnostic
workup, including lumbar puncture, showed albuminocytologic dissociation. Plasma exchange therapy was
initiated, but severe nocturnal neuropathic pain persisted, exacerbating during treatment. Conventional
pain medications were ineffective, prompting a multimodal approach.

Combining hydromorphone and lorazepam provided significant pain relief, enabling completion of
plasmapheresis sessions. This regimen, supplemented with gabapentin, proved effective in managing both
GBS-associated and treatment-induced pain.

This case underscores the debilitating nature of GBS-related pain and the importance of tailored pain
management strategies. While conventional agents may fail, a multimodal approach, including opioids and
adjunctive medications, can offer relief, facilitating essential treatments like plasmapheresis. Careful
monitoring is imperative to mitigate risks associated with potent analgesics. Our experience contributes to
the armamentarium for managing GBS-related pain, emphasizing individualized care to improve patient
outcomes.

Categories: Neurology, Internal Medicine, Therapeutics

Keywords: therapeutic plasmapheresis, acute inflammatory demyelinating polyradiculoneuropathy, multi-modal
pain management, sensory gbs, pain refractory to treatment

Introduction
Guillain-Barre syndrome (GBS) is an acute post-infectious polyradiculoneuropathy where cross-reactive
autoantibodies target host antigens, resulting in demyelination and axonal degeneration of motor, sensory,
and autonomic nerve fibers [1,2]. The characteristic presentation is a symmetric, ascending weakness with
decreased or absent deep tendon reflexes. Acute inflammatory demyelinating polyneuropathy (AIDP) is a
phenotype within the GBS spectrum [1].

GBS occurs when cross-reactive autoantibodies, which form usually after a gastrointestinal or respiratory
infection, target host axonal antigens of peripheral myelin or Schwann cells. This attack leads to immune-
mediated segmental demyelination and axonal degeneration of motor, sensory, and autonomic nerve fibers
[2]. This results in the characteristic symmetric and ascending flaccid paralysis. Autonomic dysfunction can
present in the form of arrhythmias, ileus, and the feared respiratory compromise. In addition to other
manifestations, demyelination of peripheral and autonomic nerve fibers can lead to severe neuropathic,
radicular, and/or musculoskeletal pain. Pain is a common but variable manifestation affecting 55-89% of
patients [3]. Such pain can precede the ascending weakness and persist long into recovery.

Case Presentation
A 52-year-old gentleman presented to the emergency department with three days of worsening and
progressively ascending bilateral leg weakness, accompanied by lower leg myalgias and paresthesia in distal
toes. Three weeks prior, he was diagnosed with a flu-like illness after developing a fever, cough, and
myalgias. He first noticed muscle soreness in his feet, which then progressed to severe lower leg weakness.
The patient had difficulty getting out of bed and ambulating due to the weakness in his feet. The weakness
then ascended bilaterally to his ankles and then to his thighs.

How to cite this article

Titus J, Sarmiento B, Crouse R (July 12, 2024) Management of Severe Pain in a Case of Sensory Guillain-Barre Syndrome. Cureus 16(7): e64432.
DOI 10.7759/cureus.64432
 On examination, the patient had a visibly anxious affect with hyporeflexia of the biceps, triceps, Achilles,
and patellar reflexes. Additionally, there was loss of vibratory, temperature, and pinprick sensation in his
lower extremities up to the level of the medial malleolus bilaterally. Laboratory tests, including blood count
and metabolic panel, were unremarkable as well as CT/MRI head/spine imaging. Lumbar puncture showed an
albuminocytologic dissociation with an elevated protein of 167 mg/dL, zero white blood cells, one red blood
cell, and normal glucose.

The patient received six sessions of plasma exchange therapy. Throughout the course of his two-week
hospitalization, he experienced severe, debilitating neuropathic pain described as burning in his legs, arms,
shoulders, and lower back that was predominantly nocturnal and associated with the onset of
plasmapheresis treatment. Initial pain management included acetaminophen, ketorolac, methocarbamol,
gabapentin, and lidocaine patches.

Despite this, the tear-inducing neuropathic pain that peaked around 1-3 AM led to sleepless nights,
described as “I am burning alive.” Further pain management included trials of pregabalin, carbamazepine,
duloxetine, oxycodone, and baclofen. The most effective pain medication regimen that helped with
plasmapheresis-associated and nocturnal episodes of pain was a combination of hydromorphone 0.5 mg
with lorazepam 1 mg that was given together every four hours. The patient's pain management regimen
eventually provided him with relief (Table 1).

Drug Medication Class Dosage Used Level of Pain Relief*

Gabapentin Anticonvulsant 900 mg TID Minimal

Carbamazepine Anticonvulsant 200 mg TID None

Pregabalin Anticonvulsant 75 mg BID None

Duloxetine SNRI 30 mg QHS None

Ketorolac NSAID 15 mg Q8H None

Acetaminophen Non-opioid analgesic 1000 mg Q6H None

Methocarbamol Skeletal muscle relaxant 1000 mg Q8H None

Baclofen Skeletal muscle relaxant 20 mg TID Minimal

Lidocaine 4% patch Local anesthetic Two patches BID None

Oxycodone Opioid 10 mg TID Minimal

Hydromorphone Opioid 0.5 mg Q4H Moderate

Lorazepam Benzodiazepine 1 mg Q4H Moderate

TABLE 1: Pain Medications, Dosing, and the Level of Pain Relief

*Pain Relief is measured by the change in the patient’s morning pain scale (1-10) from prior to starting that medication: with no pain relief (change by 0),
minimal pain relief (change by 1), moderate pain relief (change by 2-3), and significant pain relief (change by 4+).

SNRI: serotonin and norepinephrine reuptake inhibitor, NSAID: nonsteroidal anti-inflammatory drug.

Discussion
GBS can be a debilitating AIDP. The primary focus of GBS treatment is to address the underlying immune
response and pain management. Refractory pain in GBS can lead to treatment dilemmas since conventional
medical treatments can prove to be ineffective. Characteristic pain in GBS can be multifaceted, presenting in
various forms. The pathophysiology can include neuropathic pain, which is a result of nerve damage leading
to a burning, stabbing pain, along with musculoskeletal pain. The approach to pain management is often
multimodal, including medications and supportive therapies such as analgesics and opioids for severe pain.
Opioids are reserved for second- and third-line treatments given the risk of dependency. Neuropathic
treatment medications include gabapentin, pregabalin, and tricyclic antidepressants. Nonpharmacological
treatments include physical therapy (PT) and transcutaneous electrical nerve stimulation (TENS).

In this atypical GBS case, muscle and radicular pain preceded weakness, which is found in only one-third of
patients [4]. The extremely severe nocturnal neuropathic pain was unrelieved with many of the first- and
second-line agents used for GBS-related pain. When pain is refractory, such as in our patient, the

2024 Titus et al. Cureus 16(7): e64432. DOI 10.7759/cureus.64432 2 of 4

 pathophysiology can include worsening severe nerve damage secondary to extensive demyelination and
axonal damage, and variances in metabolic rates affecting efficacy. Advanced pharmacological therapies
include intravenous immunoglobulin (IVIG) and plasmapheresis, which are mainstays of GBS treatment.

Pain management is a key component of supportive care in GBS patients, especially when compounded by a
psychological component due to anxiety. Gabapentin and carbamazepine have proven efficacy in
neuropathic pain in GBS patients compared to placebo [5], yet carbamazepine provided no relief. In fact,
first-line pain medication options usually do not provide adequate relief, as evidenced by the fact that 75%
of GBS patients require oral or parenteral opioids [5-8]. Other management options can include
interventional procedures such as nerve blocks or epidural analgesia, which were not used in our patient.
Given the severe mental stressor of pain in such a condition, psychological support is encouraged through
the use of cognitive-behavioral therapy (CBT) to help patients cope with chronic pain. The effective pain
medication regimen is noted in (Table 2). This regimen provided moderate to significant pain relief when
used together, especially during plasmapheresis sessions, and also helped reduce anxiety.

Drug Medication Class Dosage Used

Gabapentin Anticonvulsant 900 mg three times daily

Hydromorphone Opioid 0.5 mg every 4 hours

Lorazepam Benzodiazepine 1 mg every 4 hours

TABLE 2: Effective Pain Medication Regimen

The table has been created by the authors with regard to the patient's treatment regimen.

Respiratory status monitoring, such as negative inspiratory force (NIF) checks, is critical for GBS patients,
especially when receiving a cocktail regimen of combined opioids and benzodiazepines [5,9].

The complexity of this disorder requires a multidisciplinary approach with neurologists, pain specialists,
physical therapists, and psychologists. Regular reassessment of pain and progression of GBS is necessary.
This case highlights how excruciating GBS-related pain can be and how critical pain management is when
providing supportive care for GBS patients. Although GBS pain is common, with 55-89% of GBS patients
reporting pain in the acute setting, its manifestations are variable [3]. Studies have shown efficacy in agents
such as gabapentin and carbamazepine for GBS neuropathic pain compared to placebo [4]. However, the pain
in this case was unrelieved by many of the first- and second-line agents.

First-line pain medications usually do not provide adequate relief, as evidenced by the fact that 75% of GBS
patients require oral or parenteral opioids [5]. The hydromorphone 0.5 mg and lorazepam 1 mg cocktail, with
standing gabapentin 900 mg three times daily, provided significant pain relief when used together and even
allowed for the completion of the patient’s plasmapheresis sessions. It is critical to monitor respiratory
status in GBS patients, especially in patients receiving such a cocktail. By outlining the above strategy, we
hope to provide another tool in managing GBS-related pain.

Conclusions
Pain refractory to treatment in GBS poses a significant challenge, requiring innovative and individualized
approaches to management. While conventional treatments provide relief for many, a subset of patients
needs more intensive and multidisciplinary strategies to manage their pain effectively. Ongoing research
and clinical advancements hold promise for better understanding and treating this debilitating aspect of
GBS. By providing a case of acute inpatient management of GBS-related pain, we hope to summarize some
of the available options for neuropathic pain relief.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Joane Titus, Bernard Sarmiento, Roger Crouse

Acquisition, analysis, or interpretation of data: Joane Titus, Bernard Sarmiento, Roger Crouse

Drafting of the manuscript: Joane Titus, Bernard Sarmiento, Roger Crouse

2024 Titus et al. Cureus 16(7): e64432. DOI 10.7759/cureus.64432 3 of 4

 Critical review of the manuscript for important intellectual content: Joane Titus, Bernard Sarmiento,
Roger Crouse

Supervision: Bernard Sarmiento, Roger Crouse

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.

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