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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 6, November/December 2017
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Discussion
Although GBS has occasionally been reported after cardiac
surgery, there is no case report in the literature of MFS after
coronary artery bypass surgery.
5
To our knowledge, we describe
the first case of MFS after coronary bypass surgery.
Although cardiac surgery with CPB may increase the
incidence of MFS and GBS, the pathological mechanism is
unclear.
6
A humoral immune response with deposition of
complements and immunoglobulins and a cellular response
of infiltrating macrophages and T cells are the most common
hypotheses on the underlying mechanism of these syndromes.
7
After cardiac surgery, several factors may be triggered to initiate
an inflammatory response. These include cardiopulmonary
bypass (extracorporeal circulation), ischaemia and reperfusion
injury.
When patients present with rapidly progressive paralysis, a
diagnosis of GBS and variants such as MFS need to be made
as soon as possible. The diagnosis is largely based on clinical
patterns because radiological and diagnostic markers are not
available for most variants of the syndrome. MFS is a clinical
diagnosis, but additional investigations may be helpful or even
necessary for confirmation.
Examination of CSF is important, especially to exclude other
causes of weakness associated with an increase in CSF cell
count.
8
Nerve conduction studies may help support the diagnosis,
to discriminate between axonal and demyelinating subtypes, but
nerve conduction abnormalities are most pronounced two weeks
after the start of weakness.
9
Severe, generalised manifestations of GBS and MFS with
respiratory failure affect 20 to 30% of cases.
10
Treatment with
intravenous immunoglobulin or plasma exchange is the optimal
management approach, alongside supportive care. Intravenous
administration of high-dose immunoglobulin was found to be as
effective as plasma exchange.
11
Conclusion
MFS, which is a variant of GBS, is a rare but severe neurological
complication after cardiac surgery. Cardiac surgery may be
a trigger for immune-mediated responses and may cause
devastating complications. It is important to be alert to
de novo
autoimmune and unexpected neurological disorders such as
MFS after coronary bypass surgery.
References
1.
Wakerly BR, Uncini A, Yuki N,
et al.
Guillain–Barre and Miller–Fisher
syndromes – new diagnostic classification.
Nat Rev Neurol
2014;
10
(9):
537–544.
2.
Mori M, Kuwabara S, Yuki N. Fisher syndrome: clinical features,
immunopathogenesis and management.
Expert Rev Neurother
2012;
12
(1): 39–51.
3.
Sejvar JJ, Baughman AL, Wise M,
et al
. Population incidence of
Guillain–Barre syndrome: a systematic review and meta-analysis.
Neuroepidemiology
2011;
36
(2): 123–133.
4.
Dagklis IE, Papagiannopoulos S, Theodoridou V, Kazis D,
Argyropoulou O, Bostantiopoulou S
.
Miller–Fisher syndrome: Are anti-
GAD antibodies implicated in its pathophysiology?
Case Rep Neurol
Med
2016;
2016
: 3431849.
5.
Hekmat M, Ghaderi H, Foroughi M, Mirjafari A. Guillain–Barre
syndrome after coronary bypass graft surgery: A case report.
Acta Med
Iran
2016;
54
(1): 76–78.
6.
Cingoz F, Tavlasoglu M, Kurkluoglu M, Sahin MA. Guillain–Barre
syndrome after coronary artery bypass surgery.
Interact Cardiovasc
Thorac Surg
2012:
15
(5): 918–919.
7.
Hartung HP, Willison HJ, Kieseier BC. Acute immunoinflammatory
neuropathy: Update on Guillain–Barre syndrome.
Curr Opin Neurol
2002;
15
: 571–577.
8.
Van den Berg B, Walgaard C, Drenthen J, Fokke C, Jacobs BC, Van
doorn PA. Guillain–Barre syndrome: pathogenesis, diagnosis, treatment
and prognosis.
Nat Rev Neurol
2014;
10
: 469–482.
9.
Hadden RD, Cornblath DR, Hugbes RA,
et al
., for the plasma
exchange/sandoglobulin Guillain–Barre syndrome trial group.
Electrophysiological classification of Guillain–Barre syndrome: Clinical
associations and oucome.
Ann Neurol
1998;
44
: 780–788.
10. Fokke C, Van den Berg B, Drenthen J, Walgaard C, Van Doorn PA,
Jacobs BC. Diagnosis of Guillain–Barre syndrome and validation of
Brighton criteria.
Brain
2014;
137
: 33–43.
11. Van der Meche FG, Schmitz PI. A randomized trial comparing
intravenous immune globulin and plasma exchange in Guillain–Barre
syndrome. Dutch Guillain–Barre study group.
N Eng J Med
1992;
326
:
1123–1129.