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Título

Botulism as differential atypical Guillain-Barre syndrome in neighboring transplant patients hospitalized simultaneously: report of two cases

Descrição do caso

The Guillain-Barré Syndrome (GBS), acute inflammatory demyelinating polyradiculoneuropathy, commonly presents with ascending paraparesis, areflexia and cerebrospinal fluid (CSF) protein-cytological dissociation. Atypical presentations with cranial nerves and non-ascending involvement suggest investigation of other conditions such as botulism, inflammatory myopathies, myelopathies, myasthenia gravis, neuromuscular syndromes(Miller-Fisher and Lambert-Eaton) and others metabolic-toxic polyneuropathies. Cases: two neighboring transplanted patients were admitted simultaneously presenting a similar syndrome dependent on intensive support for subacute and progressive installation cervical and proximal limb paresis, dysphagia, hyporeflexia, and respiratory deterioration. Electroneuromyography(ENMG) showed presynaptic dysfunction, suggestive botulism. Case 1: Male, 19 years old, kidney transplant, immunosuppressant tacrolimus, admitted 10 days after the symptoms onset, outside the antitoxin treatment indication period. He received clinical support, oxygen non-invasive ventilation and hospital discharge after 28 days partially symptoms recovered. Case 2: Male, 50 years old, bilateral lung transplant, immunosuppressant cyclosporine, admitted 5 days after same symptoms onset progressing to respiratory failure needing orotracheal intubation and mechanical ventilation. Health authorities were notificated for epidemiological-clinical suspicion of botulism, antitoxin antibody administration and serological antitoxin collection were performed, later undetected. After 23 days of mechanical ventilation with 3 extubation failures, he was discharged from the hospital, on spontaneous breathing and significant motor recovery. Discussion: The two cases show the intensive care unit (ICU) management of patients with suspected atypical GBS that should include the search for differential diagnoses and knowledge of therapeutic possibilities. Generally negative tests for botulism occurs due to investigation after serum toxin have fallen below detectable limit. Therefore, the importance of early diagnostic suspicion.