*3.2.1 Hospital clinical evolution*

Day 1. During her first hours in the emergency service, she presented acute respiratory distress, which is why advanced management of the airway was decided and she was admitted to the Intensive Care service, starting an infusion of Midazolam at 100 mcgkghr. Laboratories Hematic biometrics: leukocytes 14,140 leu/μl, neutrophils 59.6%, lymphocytes 29.7%, hemoglobin 14.8%, hematocrit 44.2%, platelets 434 thousand, ESR 20 mm/h, PCT <0.5 ng/ml, CRP <0.5 mg/L. Liver function tests: BT 0.37 mg/dl, BD 0.11 mg/dl, BI 0.26 mg/dl, TGO 34 IU/L, TGP 21 IU/L, GGT 9 IU/L, CK 28.9 IU/L, CK-MB 28 IU/L. Blood chemistry and kidney function tests: glucose 96 mg/dL, urea 34 mg/dL, BUN 16 mg/dL, creatinine 0.38 mg/dL.

Pediatric Neurology Assessment. Neurological examination with patient under sedation with hyporeflexic isochoric pupils, with a tendency to miosis, facial symmetry, motor with force in the upper extremities proximal 2/5 and distal 1/5 (assessed prior to sedation), lower extremities proximal force and distal 0/5 REM triceps and biceps decreased, bilateral absent patellar and achilleum, non-clonus flexor plantar response, preserved sensitivity, pain withdrawal, rest apparently normal. Patient with clinical evolution of GBS with rapid progression to compromise at the level of the respiratory and bulbar muscles as a poor prognostic factor, therefore, it was decided to start intravenous immunoglobulin at a dose of 1 grkg for 2 days. Lumbar puncture: clear, colorless, transparent liquid, 2 cells, 60% monocytes, negative erythrocytes, glucose 54 mg/dL, chloride 110 meq/L, proteins 103 mg/dL, pandy positive (+), pH 7.6, lactate 1.4, no bacteria, negative coagglutination. Simple and contrasted CT of the skull: without structural alterations and/or abnormal reinforcements. Chest X-ray: no bone structural alterations, no atelectasis, consolidation or pneumothorax.

Day 2. During her 2nd day, she presented a quantified fever>38 degrees Celsius with previous laboratories within normal parameters, but antimicrobial therapy was decided with a double antimicrobial scheme with Cefotaxime and Vancomycin. Neuroconduction study is requested. Study report: abnormal suggestive of GBS with axonal component (see **Figure 2**). After obtaining a neuroconduction study, medical treatment was started with intravenous immunoglobulin (IVIG) at a dose of 1 gr/kg for 2 days.

Day 7. For 7 days in the intensive care service, she was maintained with ventilatory mechanical support with orotracheal intubation, with poor clinical motor evolution and absence of spontaneous respiratory movements as well as protective reflexes of the airway, therefore, due to the condition neurological, it was decided to perform a tracheostomy to avoid subsequent complications.

Day 8. Sedation based on Midazolam is withdrawn, and analgesic treatment with Ketorolac and paracetamol is continued, without complications.

Day 11. Patient establishes poor verbal communication and begins oral intake based on clear liquids with adequate tolerance. Cough reflex absent.

Day 17. Concludes double antimicrobial regimen with Cefotaxime and Vancomycin (15-day regimen).

Day 19. Progression of oral feeding with a polymeric diet and later a soft diet with adequate tolerance.

Day 23. Food based on a normal diet without eventualities. Gradual evolution with clinical improvement in mobility of the right upper limb and shoulder girdle.

Day 33. Increased mobility of the right hand, left hand, feet in dorsoflexion, and pronosupination.

Day 38. Increased mobility of the bilateral shoulder girdle and hip.




#### **Figure 2.** *Neuroconduction study (female 7 years old).*

*Recurrence of Guillain Barré Syndrome in Patient Pediatric with Presentation of Two Different… DOI: http://dx.doi.org/10.5772/intechopen.96358*

Day 39. Female patient who deserved mechanical ventilatory support for 39 days, progressing with gradual clinical improvement, deciding on a programmed withdrawal of the ventilator without complications, continuing with medical treatment with pulmonary physiotherapy, gentle aspiration of secretions if necessary and supplemental oxygen support, with no evidence of respiratory distress.

Day 40 - Day 43. Multidisciplinary treatment with neurological and pulmonary rehabilitation, education to a family support network for management and care of tracheostomy. Neurological examination: favorable evolution, strength 2/5 on the Daniels scale in the upper extremities, strength 0/5 on the Daniels scale in the lower extremities (Hughes IV Scale - patient confined to bed or chair without the ability to walk), no compromise respiratory, preserved brain stem reflexes. Laboratories: results are collected as part of the GBS protocol in pediatric patients with IgM AC. Anti - Helicobacter Pylori, negative report.

Patient who presented gradual clinical improvement, which is why he was discharged home with a tracheostomy, without supplemental oxygen, tolerating oral route. It is sent for evaluation and follow-up by the neurological rehabilitation and otorhinolaryngology service for medical follow-up due to underlying pathology.
