Objective:

To present a case of Guillain-Barré Syndrome (GBS) with an unusual presentation of severe back pain with hyperreflexia, highlight the diagnostic challenge of identifying GBS with an atypical early courses, and outline the potentially deadly complications of severe dysautonomia in GBS.

Background:

GBS is a post-infectious polyradiculoneuronopathy that commonly presents with motor weakness and areflexia. Although hyporeflexia is typically a hallmark, some patients present with preserved or exaggerated deep tendon reflexes (DTRs) initially. Furthermore, isolated severe back pain is a rare and often overlooked symptom that can result in misdiagnosis or delay to diagnosis. Understanding these atypical presentations is critical for timely intervention. 

Design/Methods:

n/a

Results:

A 65-year-old female with no significant past medical history presented with acute progressive bilateral paresthesias after lifting heavy objects at home, which progressed over two days to severe intractable neck and back pain, and constipation leading to her presentation to the emergency department. Initial neurologic exam revealed hyperreflexia, raising suspicion for traumatic myelopathy; however, imaging was unremarkable. Over the course of hospitalization, pain control was challenging and required multimodal interventions. Five days after symptom onset, the patient developed severe dysautonomia with hemodynamic lability. This was complicated by Posterior Reversible Encephalopathy Syndrome (PRES) with status epilepticus requiring intubation. Four days after extubation exam showed 2/5 strength in the lower extremities and absent DTRs. Lumbar puncture revealed albuminocytologic dissociation, solidifying the GBS diagnosis. She was treated with intravenous immunoglobulin (IVIG) which led to improvement in pain and weakness. 

Conclusions:

This case illustrates the diagnostic complexity of GBS, particularly when presenting with atypical symptoms like severe back pain and preserved or increased DTRs. The patient’s dysautonomia and resultant PRES underscore the importance of recognizing the autonomic dysfunction often associated with GBS. A high index of suspicion and comprehensive evaluation are essential in such challenging cases to ensure timely and appropriate management.