Guillain-Barré syndrome (GBS) in Sub-Saharan Africa: Experience from a tertiary level hospital in Burkina Faso

¹Department of Neurology, University Hospital Yalgado Ouedraogo, Ouagadougou, Burkina Faso, ²Department of Neurology, University Hospital of Tengandogo, Ouagadougou, Burkina Faso, ³Department of Neurology, Regional University Hospital of Ouahigouya, Ouahigouya, Burkina Faso, ⁴Department of Neurology, University Hospital of Bogodogo, Ouagadougou, Burkina Faso, ⁵Department of Neurology, University Hospital of Sourou Sano, Bobo Dioulasso, Burkina Faso

^&Corresponding author
Alfred Anselme Dabilgou, Department of Neurology, University Hospital Yalgado Ouedraogo, Ouagadougou, Burkina Faso

Introduction    

Guillain-Barré Syndrome (GBS) is an acute inflammatory disorder of peripheral nerves characterized by rapidly progressive, symmetric weakness, and areflexia. Respiratory insufficiency develops in about 25% of cases, rendering mechanical ventilation crucial and long-term hospital admission necessary [1]. The annual incidence of GBS ranges from 0.81 to 1.89 cases per 100,000 population increasing linearly with age with a sex ratio of 1.5 [1]. Acute respiratory failure develops in 20-30% of patients [2]. Admission to the ICU is recommended for patients with GBS who have imminent respiratory insufficiency, severe autonomic dysfunction with cardiovascular instability, severe swallowing dysfunction and/or diminished cough reflex or rapidly progressive weakness [3]. Management of GBS requires a multidisciplinary approach including supportive medical care and immunotherapy. Intravenous immunoglobulin and plasma exchange are proven and equally effective treatments for GBS [4]. In Sub Saharan Africa, studies on GBS are rare. To our knowledge, the first study on GBS in Burkina Faso published in 2004 by Millogo focused on Guillain-Barré Syndrome in HIV-infected patients [5]. Since then, no further study has been carried out on GBS in Burkina Faso. The objective of our study was to determine the epidemiological, clinical and therapeutic profile of Guillain-Barré Syndrome GBS admitted in neurology department of a tertiary hospital in Burkina during the last 18 years.

Methods     

Study location

Burkina Faso is a French speaking country located in West Africa without access to the sea. It covers an area of 274,200km² and its population was estimated in 2016 at 19,034,397 inhabitants. Ouagadougou is its capital and the largest city of the country. The city has public health infrastructures such as the Yalgado Ouédraogo University Teaching Hospital, Tingandogo University Teaching Hospital, Charles De Gaule Pediatric University Hospital, Bogodogo Hospital and many private health infrastructures. The department of neurology has been in existence since March 2003. It has a capacity of 23 beds. The neurology department welcomes all patients suffering from peripheral neuropathies, myasthenia gravis and myopathies. The department does not have an electroneuromyography machine, a key examination for the diagnosis of peripheral neuropathies.

Study profile

We conducted a cross-sectional study whose data collection covered the period from September 1, 2003 to July 31, 2020 (18 years old).

Population study

The study was based on data from adult patients (> 15 years of age) admitted in the Neurology department for GBS in the period from 2003 to 2020. GBS diagnosis was based on Asbury and Cornblath criteria [6]: (1): progressive motor weakness, (2): areflexia. Patients with incomplete or missing medical data were excluded from the study.

Data collection and analyzed

Data was collected from clinical records, hospitalization and discharge registers, and from patients´ death registers. The study included socio-demographic data (age, sex, professional category, residence, level of education, marital status), clinical data (history, presence or absence of inaugural events, functional signs, installation mode, results of the neurological examination, hospital stay), paraclinical data (detection of a biological inflammatory syndrome, results of the cerebrospinal fluid (CSF) analysis, electroneuromyography results). The data obtained were entered and analyzed on a microcomputer using Epi info software version 7.2.2.6. The graphs were produced with Excel 2010 software. The results were expressed as a percentage and as an average.

Ethical approval and consent to participate

This study was approved by the Ethical board of medical school of Joseph Ki Zerbo University and the local ethical Committee of Yalgado Ouedraogo University Teaching hospital. The confidentiality of patient's data was taken into account.

Results     

Frequency

Our study included 35 patients with Guillain-Barré Syndrome, as 1.9 cases per year.

Socio-demographic characteristics

The majority of patients were female (60%). The mean age of the patients was 27.9 years with extremes of 15 and 68 years. Patients under the age of 35 years of age accounted for 60 percent of the study population. Table 1 shows the patients with GBS age distribution.

Clinical characteristics

The most common initial symptom was weakness in the extremities in 32 patients (91.4%) and paresthesia in 15 (42.9%) patients. Motor deficit involved four limbs in 21 patients (65.6%) and both lower limbs in 14 patients (11.4%). The mode of onset was progressive in all the patients. The motor deficit was symmetrical in 33 (94.3%) patients, asymmetrical limb weakness in 2 (5.7%) and ascending in all the patients (100%). The most common predisposing factors were pregnancy and post-partum in 10 (28.5%) patients. History of infection was present in 5 (14.2%) patients. The patient admission time was 14 days with extremes of 4 and 28 days. Fourteen patients (40%) were hospitalized during the extension of paralysis phase and 21 (60%) during the plateau phase. The mean duration of the extension and plateau phase was 7.6 days and 46.4 days, respectively. The neurological examination on admission revealed lower limbs paralysis with abolition of tendon reflexes in all patients. Flaccid tretaplegia was noted in 15 patients, trauma in 12 (34.3%) patients and paraplegia in 4 (11.4%). The pattern of paralysis was proximo-distal in 15 (42.9%) patients, distal in 12 (34.3%) patients and proximal in 8 (22.8%) patients. The other abnormalities were represented by neuro-vegetative disorders in 34 patients and objective sensitivity disorders in 25 patients. Clinical manifestations of GBS at the time of presentation were listed in the Table 2. The pattern of paralysis was proximo-distal in 15 (42.9%) patients, distal in 12 (34.3%) patients and proximal in 8 (22.8%) patients. The other abnormalities were represented by neuro-vegetative disorders in 34 patients and objective sensitivity disorders in 25 patients. Clinical manifestations of GBS at the time of presentation were listed in the Table 2. The pattern of paralysis was proximo-distal in 15 (42.9%) patients, distal in 12 (34.3%) patients and proximal in 8 (22.8%) patients. The other abnormalities were represented by neuro-vegetative disorders in 34 patients and objective sensitivity disorders in 25 patients. Clinical manifestations of GBS at the time of presentation were listed in the Table 2.

Lumbar puncture performed in 31 (88.5%) patients demonstrated albuminocytologic dissociation in 15 patients or 48.38% of cases. Routine nerve electrophysiology was performed in six (17.14%) patients. Of them, four (66.7%) patients had demyelinating forms and two (33.3%) mixed forms. The etiology of GBS was undetermined in 27 (77.1%), HIV infection in 3 (8.6%), viral hepatitis B in 3 (8.6%) patients and helicobacter pylori in 2 (5.7%) patients.

Treatment

The treatment consisted of high dose corticosteroid therapy first injectable (500 mg to 1g per day) then oral (80%). Vitamin therapy was use only or in association in 65.71% of patients. No patient was treated with intravenous immunoglobulin or plasma exchange. Supportive treatment consisted of physiotherapy (45.71%), low-molecular-weight heparin (37.14%) and of oxygen therapy (11.42%).

Clinical outcome

The average length of hospital stay was 21.25 days. The severity of the disease ranged from grade 3 to grade 5 of GBS disability score. Complications during hospitalization were pneumonia in 6 (17.14%) patients, urinary tract infection in 2 (5.71%) and deep vein thrombosis in a patient (2.85%). Five cases of death were recorded (14.3%). One case of death was recorded during the extension phase (2.8%) and three cases (8.6%) during the plateau phase. One patient was transferred to intensive care for respiratory decompensation. On discharge, complete functional recovery was noted in one (2.6%) patient and partial in 17 (48.6%) patients.

Discussion     

This cross-sectional study described the epidemiological, clinical and therapeutic profile of GBS admitted in neurology department in Burkina Faso during the last 18 years. The frequency of GBS in our context was very low, only 1.9 cases per year. This situation could be explained by the lack of neurologists and neurophysiologist in the country. The mean age of patients with GBS was 27.9 years, comparable to that found by Basse in Senegal (33.9 years) [7]and Saisha in Zambia (33.6 years) [8]. Young adults were more affected than the older patients [9]. Our study showed a predominance of women (60%), in line with the study of Basse in Senegal (69.23%) but in contrast with most studies who reported a clear male predominance [4]. About 14.2% of patients had experimented infectious disease prior to their admission in neurology department. According to the literature, more than two-thirds of GBS cases are preceded by acute infection within 3-4 weeks [10].

This low history of infections could be explained by the long wait times for patients to be hospitalized. Pregnancy and postpartum were present in 28.5% of patients, in lower percentage than that found by Basse in Senegal (63.6%) [7]. The risk of GBS is lower during pregnancy and increases post-delivery particularly in the first 2 weeks after delivery [11]. Diagnosis of GBS is based on the patient history and neurological, electrophysiological and cerebrospinal fluid (CSF) examinations [6] but in resource limited settings, the diagnosis is usually made clinically with the support of a few laboratory investigations. Lumbar puncture was performed in 88.5% of cases but electromyogram was available in few patients (17.1%). The low rate of completion of electromyogram could be explained by the limited number of devices (two in total for the whole country), the high cost of this examination (30,000 fcfa) and the severity of the patients. An albinuno-cytological dissociation was found in 42.8% of cases, approaching the rate found by Basse et al. in Senegal (45.4%) [7].

The study of cerebrospinal fluid can be normal in the first week but shows albuminocytologic dissociation after two weeks [12]. The electromyogram showed demyelinating lesions in 66.7% of cases and axono-myelinic in 33.3% of cases. The preponderant myelinic involvement is in favor of AIDP which constitutes the most frequent form of GBS (75 to 80%) [13] . In the majority of cases, the causes of GBS were undetermined linked to the lack of financial resources.

However, our study was to highlight certain causes. About eight percent of patients (8.6%) were HIV positive, lower than that found in the study of Millogo in 2004 (20%) [5] and Saisha in Zambia in 2015 (82%) [8]. According to Thornton, HIV infection is more frequent cause of GBS in sub-Saharan Africa [14]. Viral hepatitis B was also noted in 5.7% of patients, in agreement with several data from the literature [15]. The presence of HBs Ag is found in the CSF of some patients with GBS [16]. Gastrointestinal infection with Helicobacter pylori was identified in 5.7% of patients. To our knowledge, we have not been able to identify any cases in the literature. Therapeutically, corticosteroid therapy was the main treatment for GBS in our setting (80%), in agreement with the study by Basse in Senegal (53.4%) [7]. This is due to the high cost of immunoglobulins, the treatment of choice for GBS. Corticosteroids were recommended in treating patients with refractory or severe GBS as immunosuppressants [17].

Physiotherapy was performed in 45.71% of patients but some authors argued that there was no evidence of the impact of physiotherapy in the management of GBS patients (44-46). Functional reduction be considered for patients with a GBS [2]. The mortality rate recorded in our series (14.3%) was comparable to that recorded by Basse in Senegal (10.2%) [7]. This mortality was high compared to that reported in North America and Europe (1-5%) [18]. This high mortality rate in our context could be explained by the presence of severe forms early in hospitalization (tetraplegia, damage to the bulbar nerves, respiratory failure) and the lack of intensive neurological care. The causes of death are notably linked to respiratory complications and ventilatory support is necessary in 15 to 20% of cases [19]. Most patients with GBS require admission to an intensive care unit (ICU) under the care of physicians who are familiar with the medical complications that develop in paralyzed Intensive Care Unit patients [20]. A patient was transferred in resuscitation unit, lower than in the study of Basse (20.5%) [7] due to low reception capacity of the service.

Limitations of the study

Our study has several limitations. This is a retrospective study with inherent biases in this study profile (incomplete or not found files; lack of data on the course of the disease after the patients have been discharged). This hospital based study included patients with severe GBS, explaining the low number of patients included. Electromyogram was performed in few patients who did not allow us to specify the electrophysiological forms of GBS.

Conclusion     

Guillain-Barré Syndrome was infrequent in Burkina Faso. Steroids were the main treatment with high mortality. It is necessary to develop medico-technical skills.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

AAD, AD, RK, MMK and JMAK had contributed to the data collection or processing, analysis or interpretation, literature research and writing. CN, KK and JK had contributed to concept and design of the study All the authors read and approved the final manuscript.

Acknowledgments     

I want to thank Mrs Zongo L Carine Patricia for translation.

Tables     

Table 1: distribution of patients with GBS by age group at admission

Table 2: clinical manifestations of GBS at the time of presentation

References