Naeem, Muhammad

Nasrullah, Muhammad

Zaheer, Mohsin

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Pakistan Journal ofNeurological Sciences (PJNS)Volume 3 | Issue 1 Article 24-2008Seasonal Variation and Sex Distribution Inpatientswith Guillain-Barre SyndromeMohsin ZaheerKing Edward Medical University and Mayo HospitalMuhammad NaeemKing Edward Medical University and Mayo HospitalMuhammad NasrullahKing Edward Medical University and Mayo HospitalFollow this and additional works at: https://ecommons.aku.edu/pjnsPart of the Neurology CommonsRecommended CitationZaheer, Mohsin; Naeem, Muhammad; and Nasrullah, Muhammad (2008) "Seasonal Variation and Sex Distribution Inpatients withGuillain-Barre Syndrome," Pakistan Journal of Neurological Sciences (PJNS): Vol. 3 : Iss. 1 , Article 2.Available at: https://ecommons.aku.edu/pjns/vol3/iss1/2Guillain-Barre syndrome (GBS) is an acute, immune-mediated polyneuropathy characterized by progressiveflaccid weakness of more than one limb, areflexia andabsence of any other identifiable cause along withalbumino-cytological dissociation in cerebrospinal fluid.1GBS has a worldwide distribution affecting both males andfemales from age 08 months to 81 years with somewhatmore susceptibility reported in females and no seasonalvariation.2 Incidence has been estimated to be 0.8 to 1.8per 100,000 persons per year.3On the other hand, seasonal variation has been found insome western and Pakistan-based studies.4,5 Malepreponderance has also been reported.6 These accountssuggest a heterogeneity regarding the epidemiology andelectrophysiological pattern of GBS. We undertook thisstudy to formulate an assessment on the epidemiology ofGBS in our setting, especially the questions of anyseasonal variation and male or female preponderance.Although GBS is a sporadic disease extending throughoutthe year, seasonal, identifiable outbreaks - such as thosein Columbia and Jordan - have occurred where thenumber of cases exceeded the expected incidence by 20-400 times.7,8 Another outbreak occurred in the UnitedStates in 1976 after immunization of 45 million peopleagainst swine influenza. There have been two outbreaks ofGBS in South America after rabies vaccination.9Furthermore there occurred two outbreaks in 1985, one inFinland after vaccination against poliomyelitis and theother in Japan without any identifiable cause.10METHODSThis prospective study was conducted in the Departmentof Neurology, Mayo Hospital, Lahore. The study periodstarted with the entry of first patient and extended overthe period of one full year. All patients admitted to theneurology department and those admitted in othermedical departments of Mayo hospital or elsewhere, andthose referred for specialists' opinion or nerve conductionstudies were included in the study. A detailed history fromthe patient or a relative was taken and completeneurological examination was performed along withexamination of other systems. Inclusion criteria were: (a)patients fulfilling the NINCDS criteria for Guillain-Barresyndrome; patients of all age groups; patients of bothsexes. Suspected cases of diphtheria, porphyria, hepatitisand viral xanthelasma were excluded.V O L .  3 ( 1 )   J A N - M A R  2 0 0 8P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  6O R I G I N A L  A R T I C L ESEASONAL VARIATION AND SEX DISTRIBUTION INPATIENTS WITH GUILLAIN-BARRE SYNDROMEMohsin Zaheer, Muhammad Naeem and Muhammad NasrullahDepartment of Neurology, King Edward Medical University and Mayo Hospital, Lahore, PakistanCorrespondence to: Dr. Zaheer, 17-O Chauburji Gardens Estate, Multan road, Lahore 54500, Pakistan. Tel +92 300 9412966. Email: dmzaheer@hotmail.comABSTRACTSeasonal variation and gender preponderance have not been adequately studied in Guillain-Barre syndrome (GBS). Weconducted a prospective study to investigate differences in GBS incidence between males and females and across differentseasons of the year. Patients were recruited from neurology inpatients at Lahore's Mayo Hospital, as well as those referredto our facility for nerve conduction tests. Twenty five consecutive cases were registered over one year. Of these 21(84%)were males and 4 (16%) were females, with male to female ratio of 5.5:1. Incidence was higher in summer months (Aprilto September) when 16 (64%) patients presented, while in winter (October to March) only 9 (36%) patients presented.Small peaks of incidence were found in April-May when 24% and July-August when 32% patients presented. We concludethat males are affected more than females in GBS and the condition occurs throughout the year with small peaks ofincidence in different parts of the year, especially summer.Pak J Neurol Sci 2008; 3(1):6-8V O L .  3 ( 1 )   J A N - M A R  2 0 0 8P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  7RESULTSDemographicsDuring the study period, twenty five consecutive patientswere registered. Of these, 21 (84%) patients were maleand 4 (16%) patients were females, with male-to-femaleratio of 5.2:1. The age of the patients ranged from 7 years to 70 years,with a mean of 34.72 years.  Most patients (n=20, 80%)belonged to the age group 11-50 years, with peakincidence between 11-30 years, which comprised 12(48%) patients. There were 8 (32%) patients in the agegroup 31-50 years and 4 (16%) in the age group 51-70years. There was only 1 (4%) patient who presented belowthe age of 10. The age range of 21 male patients was between 7-70years with a mean of 34.14 years.  Most patients (n=17,80.93%) presented between 11-50 years with peakincidence between 11-30 years, which comprised 10(47.61%) patients. There were 7 (33.33%) patients in theage group between 31-50 years and 3 patients (14.28%)between 51-70 years. Only 1 patient (4.76%) presentedbefore the age of 10.Four females presented at the ages of 18, 30, 38 and 65years, with a mean of 37.8 years. Seasonal VariationGBS incidence was much higher in summer months (April-September), during which 16 (64%) patients presented,whereas in the remaining half of the year (October-March)only 9 (36%) patients were seen.Overall, patients were distributed throughout the fourquarters of the year, with 7 (28%) presenting in April-June, 9 (36%) in July-September, 3 (12%) in October-December, and 6 (24%) presenting in January-March.Peaks of incidence were noted in April-May (n=6, 24%)and July-August (n=8, 32%).  DISCUSSIONWe prospectively studied 25 patients of Guillain-BarreSyndrome over a period of one year. Clinical diagnosis wasconfirmed by appropriate laboratory tests andelectrophysiological studies.Although patients presented throughout the year, smallpeaks were found at certain times, with the highestincidence in July-September. The overall incidence washigher during summer months (April-September). In onestudy, Nasrullah et al reported that the presentation ofGBS was most common between the months of July-October where 10 out of 17 (58.8%) patients presented,which is similar to our study.4 Higher peak incidence inthe form of summer epidemics is also reported by Hugheset al in northern China.6 Baoxan et al in Beijing noted anincreased incidence in late summer and early fall (July-October), which they attributed to the increased frequencyof enteric infections at that time of year.11 Higherseasonal preponderance in spring (March-May) in Taiwan5and in autumn from Stockholm is also reported.12Clustering of GBS patients is also reported by Ismail et alFigure 1. Presentation of cases by monthin winter and spring from Kuwait.13 In contrast to theabove studies, a significant relationship between seasonand Guillain-Barre Syndrome was not found by Hahn et aland Emilia-Romagna et al.14,15It is evident from the above discussion that incidence ofGBS is distributed throughout the year but small peaks ofhigher incidence are found in different parts of the year,particularly in warmer parts of the year, especially fromAsian countr ies. Although no clear seasonalpreponderance is reported in western studies, there are afew from Scandinavia which report higher incidence inautumn. This seasonal preponderance in Asian countriesmay be related to peaks of gastrointestinal infection insummer and infections of the respiratory tract in winter. Males overwhelmingly outnumbered females in our study.Although male preponderance is reported in most GBSseries, it was found to be much higher in our study. Malepreponderance (109/167, 65%) is reported by Lyu et aland was seen in both demyelinating and axonal subgroups.5 Higher prevalence in males is also reported byHughes et al, with a male to female ratio of 1.25:1.6 Malepreponderance is also reported by Nasrullah et al4 andEmil ia-Romagna et al.15 The much higher malepreponderance in our study may be due to higherexposure to infections to males in our community;alternatively, females (especial ly those with mildweakness) might not have presented for medical attentiondue to social limitations in our part of the world.REFERENCES1. Alam TA, Chaudhry V, Cornblath DR. Electrophysiological studies in the Guillain-Barre syndrome: distinguishing subtypes by published criteria. Muscle & nerve 1998;21(10):1275-9.2. Adams RD, Victor M, Ropper AH. Principles of Neurology. 6 ed: Mc Graw Hill; 1997.3. McLeod JG.Clinical Neurology International Practice and Research 1994 Apr.Vol.3 No.1: 73-93. 4. Nasrullah M, Altafullah I, Sonawala AB. Guillain-Barre Syndrome. Pak J Neurol 1995;1(4):78-82.5. Lyu RK, Tang LM, Cheng SY, Hsu WC, Chen ST. Guillain-Barre syndrome in Taiwan: a clinical study of 167 patients. Journal of neurology, neurosurgery,and psychiatry 1997;63(4):494-500.6. Hughes RA, Rees JH. Clinical and epidemiologic features of Guillain-Barre syndrome. The Journal of infectious diseases 1997;176 Suppl 2:S92-8.7. Lopez F, Lopez JH, Holguin H, Flewett TH. An outbreak of acute polyradiculoneuropathy in Columbia in 1968. American journal of epidemiology 1973;98(3):226-30.8. Sliman NA. Outbreak of Guillain-Barre syndrome associated with water pollution. British medical journal 1978;1(6115):751-2.9. Cabrera J, Griffin DE, Johnson RT. Unusual features of the Guillain-Barre syndrome after rabies vaccine prepared in suckling mouse brain. Journal of the neurological sciences 1987;81(2-3):239-45.10. Kinnunen E. Incidence of Guillain-Barre syndrome during a nationwide oral poliovirus vaccine campaign. Neurology 1989;39(8):1034-6.11. Baoxun Z, Yinchang Y, Huifen H, Xiuqin L. Acute polyradiculitis (Guillain-Barre syndrome): an epidemiological study of 156 cases observed in Beijing. Ann Neurol 1981;9:146-8.12. de Pedro-Cuesta J, Abraira V, Jiang GX, Solders G, Fredrikson S. Guillain-Barre syndrome in South-West Stockholm, 1973-1991, 3. Clinicoepidemiological subgroups. Acta neurologica Scandinavica 1996;93(2-3):175-83.13. Ismail EA, Shabani IS, Badawi M, et al. An epidemiologic, clinical, and therapeutic study of childhood Guillain-Barre syndrome in Kuwait: is it related to the oral polio vaccine? Journal of child neurology 1998;13(10):488-92.14. Hahn AF. Guillain-Barre syndrome. Lancet1998;352(9128):635-41.15. A prospective study on the incidence and prognosis of Guillain-Barre syndrome in Emilia-Romagna region, Italy (1992-1993). Emilia-Romagna Study Group on Clinical and Epidemiological Problems in Neurology. Neurology 1997;48(1):214-2.V O L .  3 ( 1 )   J A N - M A R  2 0 0 8P A K I S T A N  J O U R N A L  O F  N E U R O L O G I C A L  S C I E N C E S  8

Seasonal Variation and Sex Distribution Inpatients with Guillain-Barre Syndrome

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Seasonal Variation and Sex Distribution Inpatients with Guillain-Barre Syndrome

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