Association between Transmission Season and Degree of Severity in Guillain-Barre Syndrome

 

Mudjiani Basuki^1*, Muhammad Hamdan¹, Fidiana¹, Fadil¹, Irma Rizkika Marjianto¹

¹Department of Neurology, Faculty of Medicine, Universitas Airlangga - Dr. Soetomo Teaching Hospital, Surabaya 60285, Indonesia.

 

ABSTRACT:

Guillain-barre syndrome (GBS) is a common cause of acute severe paralysis. This weakness makes people with GBS could not move for a long time, thus disrupting the productivity of the patient. GBS usually occurs after an infectious disease in which the immune response produces cross-reacting antibodies with gangliosides in the neural membrane. Seasonal variations in GBS could be caused by the season of infectious disease that proceeds and it affects the weight of GBS. The study was conducted retrospectively, case-control study, using the hospitalized patient records of GBS patients in Dr. Soetomo Teaching Hospital, Surabaya, which meets the inclusion and exclusion criteria, from January 2013 to October 2016. GBS severity is assessed using the Medical research council (MRC) sum score. The case group was GBS with a severe severity which has a value <36. There were 82 subjects that consist of 41 case groups and 41 control groups. In the case group with the onset of transition symptoms during the transition season, there were 21 people 51.2% more than 15 the control group 36.6%. In contrast, in the control group, the onset symptom was not the transition season, 26 people 63.4% than the case group of 20 people 48.8%. However, this difference was not statistically significant with p = 0.182 and research objectives (RO) 1.82 (CI 95% 0.753−4.399). There was no correlation between the transmission season and the severity of GBS.

 

 

INTRODUCTION:

Guillain-barre syndrome (GBS) is a common cause of acute severe paralysis. GBS usually occurs after an infectious disease in which the immune response produces cross-reacting antibodies with gangliosides in the neural membrane. Infections often appear in certain seasons and the preceding symptoms are respiratory tract infections and diarrhea¹. The study in Bandung states that the highest incidence of GBS in April to May where there is a change of wet and dry seasons². While in countries with four seasons is examined when winter incidents GBS higher with the repair process is longer^3–5.

 

GBS incidence in the world is reported to be 1.1-1.8 every 100.000 cases each year. GBS incidents in Indonesia have not been reported⁶. A meta-analysis shows an increased risk of GBS by 14% in winter compared to summer⁵. The study in Iran also suggested a significant association between seasonal variation and the ratio of GBS patients treated with winter having more GBS patients⁷.

 

The seasonal variation in GBS could be caused by the season of the disease that precedes it. This variation also has an effect on the severity of the disease against GBS. GBS patients usually come to the hospital and 25% need a ventilator machine. Death occurs in 3-10% of patients and 20% morbidity occurs in survivors who cannot walk within 6 months. This impacted on neurological and neurointensive needs in certain seasons^5,8.

 

Indonesia is a tropical country that has two seasons, the dry season and the rainy season. The incidence of infection increases during the transition season. Research on the severity of GBS with seasons has not been studied in tropical countries. This encourages researchers to know the relationship between the season with the severity of GBS. Therefore neurological awareness could be further improved for better handling of GBS in certain seasons.

 

MATERIALS AND METHODS:

The subjects of this study were Guillain-barre syndrome (GBS) patients treated in Dr. Soetomo Teaching Hospital. The data were taken from January 2013 to October 2016 with the taking of research subject of a medical record of a patient with a diagnosis of GBS. The diagnosis of GBS was the ultimate diagnosis of medical records with the ICD code X G61.0, with clinically symmetrical and bilateral progressive weakness in limbs accompanied by hyporeflexia. While the severity of GBS was measured by using an Medical research council (MRC) sum score of 0-60 values before to Intravenous immunoglobulin (IVIG) therapy or plasmapheresis⁹. The number of MRC scores from 6 muscle groups, including shoulder abductors, elbow flexors, wrist extensors, hip flexors, knee extensors, and dorsiflexions of the legs on both sides. MRC score on each muscle has a value of 0-5: 0 = no contractions appear, 1= contraction without joint movement, 2= active movement but not against gravity, 3= active movement against gravity, 4= active movement against gravity and light resistance, and 5= normal strength.

 

Inclusion criteria in this research were case inclusion and control criteria. On the inclusion criteria cases, patients have the value of Medical research council (MRC) sum score <36. While the inclusion criteria of control patients were ≥36. Before the identification of the subject, the researcher conducted a test of ethics at Dr. Soetomo Teaching Hospital Surabaya, Indonesia.

 

This type of research was analytic observational by using case-control case design. The procedure of taking data using patient medical record GBS ICD-X: G61.0, then collected and recorded identity and its characteristics. While the degree of severity of GBS was assessed with MRC sum score, then recorded the onset of symptoms of GBS so that researchers know the season. All recording results are collected for further data tabulation and statistical analysis. In data processing, the data obtained are then analyzed using Chi-square statistical test using SPSS 20.0 (SPSS, Inc., Chicago, IL.).

 

RESULTS:

There were 82 subjects who consisted of 41 Guillain-barre syndrome (GBS) patients with mild severity called control and 41 GBS patients with severity referred to as cases. In the case group, 23 males (56.1%) and 18 women (43.9%) were obtained. However, the difference was not statistically significant with p = 0.49 (Table 1). The median age of the study subjects in the case group was 27 (5-63) years, whereas in the control group was 40 (13-65) years. There was a statistically significant difference in the characteristics of study subjects by age with p = 0.018 (Table 1). Clinical characteristics observed in the study subjects are presented in Table 2. From the results of data collection, it was noted that the symptoms of GBS originator could affect the severity of GBS.

 

Characteristics of subjects based on GBS trigger factors grouped into diarrhea, URI, other infections and unknown. There were 4 diarrhea risk factors (9.8%), URI of 10 people (24.4%), and other infections 9 people (22%) in the case group. While in the control group, diarrhea risk factor was 4 people (9.8%), URI of 13 people (28%) and other infections 9 people (22.0). Other infections include chickenpox, dengue fever, and unknown cause of the fever. However, this difference was not statistically significant with p = 0.747 (Table 2).

 

Table 1. Characteristics of study subjects by sex

GBS: Guillain-barre syndrome, AIDP: Acute inflammatory demyelinating polyneuropathy, MFS: Miller fisher syndrome

 

Table 2. Correlation between transition seasons and GBS severity Degrees

	GBS				P	RO (CI 95%)
	Case		Control
	N	%	N	%
Weather Dry Rainy	21 20	51.2 48.8	15 26	36.6 63.4	0.182	1.82 (0.753-4.399)
Total	41	100	41	100

GBS: Guillain-barre syndrome, RO: Research objectives

 

The difference in the proportion of onset of symptoms during the transition season and not the transition seasons in each of the subject groups could be seen in Table 2. In the case group, there were 21 people (51.2%) of the onset of symptoms during the transition season, more than the control group by 15 people (36.6%). This difference was not statistically significant with p = 0.182 with the Odd ratio of 1.82 (CI 95% 0.753-4.399). From this result, then the researcher calculate β-error of this research was equal to 75%.

 

DISCUSSION:

In this study, GBS incidence occurred in January and July, while GBS with the most severe severity in March, which is the beginning of the transition season. But when analyzed, there was no significant correlation between the transmission season with the severity of GBS. The difference in the results of this study might be due to differences in exposure of the preceding factors. Indonesia is a tropical country with little seasonal variation, so the possibility of infection that precedes GBS occurs sporadically.

 

In this study, sex characteristics were obtained (Table 1) of 82 samples which 49(60%) men and 33(40%) women. A population-based study in Chile found more men by 59% cases of GBS, with a male: female ratio of 1.47: 1. Similarly, in the epidemiological study of GBS in Brazil's tropical country, the subject of men was more than women by 56.4%^10,11.

 

In this study, the median age of the case group subjects was 27 (5-63) years compared with the control group of 40 (13-65) years. Therefore, it can be seen in the case group obtained more young age than the control group. This demographic data compared with a study of the characteristics of Guillain-barre syndrome (GBS) patients in Brazil found that the incidence of GBS type of demyelination increased in 40-59 years, whereas the incidence of high axonal GBS types was <20 years. A study in India studied 328 GBS patients found the median age was 30 years with the highest frequency in the second and fourth decades^11,12.

 

Characteristics of subjects based on GBS trigger factor obtained that the trigger factors of diarrhea were 9.8%, Upper respiratory track infection (URI) was 28.0% and 22% for other infections. However, this difference was not statistically significant with p = 0.524. This shows that in this study almost 60% of GBS incidence begins infection and URI was the most. This was consistent with the theory that GBS as an autoimmune disease induced by an infection, with two-thirds of cases having an infection before the symptoms of GBS appear. A Brazilian study in tropical climate found 55.7% of patients suffering from diseases such as influenza and 8% had diarrhea before coming to the hospital due to GBS. Preliminary diseases were also obtained in 253 GBS patients in Australia, of which 45% had ARD and 19% had diarrhea^6,8,11,13.

 

In the case group with the onset of transition symptoms during the transition season, there were 21 people (51.2%) more than 15 the control group (36.6%). In contrast, in the control group, the onset symptom was not the transition season by 26 people (63.4%) than the case group of 20 people (48.8%) (Table 2). However, this difference was not statistically significant with p = 0.182, and clinical with odds ratio of 1.82 (CI 95% 0.753-4.399). The GBS incidence associated with seasonal variations was still contradictory.

 

The increased incidence of Guillain-barre syndrome (GBS) at one time might be associated with a high incidence of infection that possibility due to weather and environmental changes. However, since there were no clear limits on climate and weather patterns that vary in some countries, including Indonesia, the analysis of the relationship between seasons and the incidence of GBS becomes very complex. A meta-analysis by Webb suggests the GBS incidence rate during winter was higher in European countries (1.28: 1), but vice versa in Latin America the GBS incidence rate is higher in summer (0.75:1). A study in northern China was obtained by Acute motor axonal neuropathy (AMAN) type in association with summer, this may be explained by the extraordinary incidence of Campylobacter jejuni infection at the time of the study. But a follow-up study in Hong Kong revealed no relationship between the seasons and the incidence of GBS. In addition to seasons, consideration should be given to socio-geographic conditions that also affect GBS            severity ^3,10,14,15.

 

Based on GBS type, Acute inflammatory demyelinating polyneuropathy (AIDP) is more common in winter, whereas axonal variants are more common in summer. This could be linked to an infection that precedes GBS. AIDP is often preceded by Acute respiratory distress (ARD), where Upper respiratory tract infection (URI) is more common in winter. While axonal variants are often preceded by diarrhea, an infection that often occurs in summer. Axonal variants are usually heavier than AIDP. An epidemiological study in Greece on GBS states there is no relationship between seasons with the severity and clinical outcomes of GBS. The distribution of GBS in a particular month or season varies by country. In general in low-temperature countries, GBS tends to occur during winter. The most prevalent GBS in spring is reported to occur in Taiwan and Israel. This suggests that weather differences may contribute to the high incidence of GBS in certain months in some countries^3,12,13,16. Patients come from different regions so that the pathogen exposure that precedes is also different. In Indonesia, the majority is a Malay race that is likely to have a different susceptibility to GBS severity than the Mongoloid and Caucasian races^14,17.

 

CONCLUSION:

In this study, there was no correlation between the transition season and the severity of GBS.

 

CONFLICT OF INTEREST:

There is no conflict of interest in this study

 

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Received on 06.11.2019           Modified on 20.01.2020

Accepted on 09.03.2020         © RJPT All right reserved