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LETTER TO THE EDITOR  
Year : 2014  |  Volume : 7  |  Issue : 6  |  Page : 270
Hypoglossal nerve palsy in a case of Guillain-Barré syndrome


1 Department of General Medicine, Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
2 Department of Neuromedicine, Bangur Institute of Neurology, Kolkata, West Bengal, India

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Date of Web Publication14-Apr-2015
 

How to cite this article:
Chakrabarti S, Pan K. Hypoglossal nerve palsy in a case of Guillain-Barré syndrome. Ann Trop Med Public Health 2014;7:270

How to cite this URL:
Chakrabarti S, Pan K. Hypoglossal nerve palsy in a case of Guillain-Barré syndrome. Ann Trop Med Public Health [serial online] 2014 [cited 2019 Sep 18];7:270. Available from: http://www.atmph.org/text.asp?2014/7/6/270/155026
Dear Sir,

Among cranial nerves, hypoglossal nerve involvement is extremely rare in Guillian-Barré Syndrome (GBS), with few case reports available in the literature. Here, the authors present a case of GBS with 12th cranial nerve involvement.

A 38-year-old nondiabetic, nonalcoholic male presented with acute onset progressive weakness in all four limbs starting from the lower limbs for the past 8 days. No history suggestive of any sensory or bladder/bowel abnormality was noted. His history including having suffered an episode of diarrhea 3 weeks earlier lasting for 2 days, which had remitted spontaneously. On examination, total areflexic flaccid quadriparesis was noticed (power of proximal muscles 1/5 according to the Modified Medical Research Council grading, in all 4 limbs) and mild left-sided facial nerve weakness. One day after admission, i.e., on the ninth day after the onset of weakness of the limbs, he developed difficulties in talking and in moving the tongue. Examination on the 12th day of illness revealed tongue atrophy and fasciculations and deviation of the tongue to the right; the findings were corroborative of right-sided hypoglossal palsy [Figure 1]. Nerve conduction study (NCS) in all four limbs was performed, which showed features compatible with demyelinating sensory-motor polyradiculoneuropathy. In addition, the left facial NCS revealed suggestions of neuropathy. The cerebrospinal fluid (CSF) study showed albuminocytological dissociation (cell count 3/cmm; all lymphocytes; protein 87 mg/dL). Magnetic resonance imaging (MRI) of the brainstem and cervical spine was normal [Figure 2]. Antiganglioside antibody evaluation showed positive results for immunoglobulin M (IgM) GM2 and GT1b, and immunoglobulin G (IgG) GM2 antibodies. Vasculitis profile, including antinuclear antibody, rheumatoid factor, complement component 3 (C3), and complement component 4 (C4), was within normal limits. A final diagnosis of GBS complicated by right-sided hypoglossal nerve palsy and asymptomatic left-sided facial nerve weakness was made. The patient was treated with intravenous immunoglobulin for 5 days at a dose of 0.5 g/kg daily. Limb weakness improved gradually over 3 weeks, whereas tongue weakness improved marginally. The follow-up at 4 months revealed almost complete recovery of muscle power, while tongue atrophy showed only partial improvement.
Figure 1: Showing right-sided deviation of tongue with atrophy; mild left-sided facial nerve weakness is also noted

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Figure 2: Showing normal brainstem and cervical spine in sagittal view MRI

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GBS is associated with cranial nerve involvement in approximately 45-75% of cases. The most common nerve to be involved is the seventh cranial nerve (facial nerve) followed by nerves to extraocular muscles (third, fourth, and sixth), and the least involvement is shown by the lower cranial nerves. [1] Among all cranial nerves, hypoglossal nerve involvement is extremely uncommon in GBS with only three cases having been reported till date. [2],[3],[4] Tan et al. reported a case of severe GBS presenting with quadriplegia and complicated by complete paresis of multiple motor cranial nerves including the hypoglossal nerve. [2] Polo et al. also mentioned a case of an atypical variant of GBS in a 23-year-old male with multiple cranial nerve palsies including of the hypoglossal nerve, where the patient developed diplopia, facial diplegia and a nasal voice, weakness of the neck and tongue muscles, dysphagia, abolition of reflexes of the left arm, and right triceps reflex, but without involvement of the respiratory muscles or other limbs. [3] Recently, Nanda et al. reported a case of a 13-year-old male who developed bilateral facial and bulbar weakness and became anarthric due to hypoglossal nerve palsy. [4] The patient required ventilation for bulbar involvement. His antiganglioside antibody panel showed positivity for IgM GM2 and GT1b, and IgG GM1, GM2, GM3, and GT1b antibodies. Those cases had in common a relatively young patient profile and features of other lower cranial nerve involvement (nasal intonation, dysphagia, respiratory difficulty). However, our patient was middle-aged, did not develop complete bulbar palsy, and recovered without need of ventilator support. Moreover, only IgM GM2 and GT1b, and IgG GM2 antibodies were found to be positive.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/ her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

 
   References Top

1.
Bradley WG, Daroff RB, Fenichel GM, Jankovic J. Neurology in clinical practice. In: Harati Y, Peter E, editors. Bosch Disorders of Peripheral Nerves. 5 th ed. Vol. 2. Philadelphia: Butterworth-Heineman, Elsevier Inc; 2008. p. 2249-356.  Back to cited text no. 1
    
2.
Tan AK, Chee MW. Fulminant Guillain-Barré syndrome with quadriplegia and total paresis of motor cranial nerves as a result of segmental demyelination. J Neurol Sci 1995;134:203-6.  Back to cited text no. 2
    
3.
Polo JM, Alañá-García M, Cacabelos-Pérez P, Ortín-Castaño A, Ciudad-Bautista J, López-Alburquerque JT. Atypical Guillain-Barré syndrome: Multiple cranial neuropathy. Rev Neurol 2002;34:835-7.  Back to cited text no. 3
    
4.
Nanda SK, Jayalakshmi S, Ruikar D, Surath M. Twelfth cranial nerve involvement in Guillian-Barre Syndrome. J Neurosci Rural Pract 2013;4:338-40.  Back to cited text no. 4
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Correspondence Address:
Subrata Chakrabarti
Doctor Hostel, Institute of Post-Graduate Medical Education and Research (IPGMER), AJC Bose Road, Kolkata - 700 020, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.155026

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