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A Case of Visceral Autonomic Neuropathy Complicated by Guillain-Barre Syndrome Accompanied with Cyclic Vomiting Syndrome-Like Disorder in a Child

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A Case of Visceral Autonomic Neuropathy Complicated by Guillain-Barre Syndrome Accompanied with Cyclic Vomiting Syndrome-Like Disorder in a Child pISSN: 2234-8646 eISSN: 2234-8840 http://dx.doi.org/10.5223/pghn.2015.18.2.128 Pediatr Gastroenterol Hepatol Nutr 2015 June 18(2):128-133 Case Report PGHN A Case of Visceral Autonomic Neuropathy Complicated by Guillain-Barre Syndrome Accompanied with Cyclic Vomiting Syndrome-like Disorder in a Child Suk Jin Hong and Byung-Ho Choe* Department of Pediatrics, Catholic University of Daegu School of Medicine, *Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea We present a case of an 8-year-old boy with visceral autonomic neuropathy complicated by Guillain-Barre syndrome. In this pediatric patient, gastroparesis was the major symptom among the autonomic symptoms. Due to the gastro- paresis, there was no progress with the oral diet, and nutrition was therefore supplied through a nasojejunal tube and gastrojejunal tube via Percutaneous endoscopic gastrostomy (PEG). After tube feeding for 9 months, the pa- tient’s gastrointestinal symptoms improved and his oral ingestion increased. The pediatric patient was maintained well without gastrointestinal symptoms for 3 months after removal of the PEG, had repeated vomiting episodes which lead to the suspicion of cyclic vomiting syndrome. Then he started treatment with low-dose amitriptyline, which re- sulted in improvement. Currently, the patient has been maintained well for 6 months without recurrence, and his present growth status is normal. Key Words: Cyclical vomiting syndrome, Dysautonomia, Gastroparesis, Guillain-Barre syndrome, Child INTRODUCTION authors experienced gastrointestinal autonomic neuropathy that was accompanied by vomiting and Guillain-Barre syndrome (GBS) refers to an acute constipation in a pediatric patient who was being demyelinating polyneuropathy with progressive as- treated for GBS. In addition, cyclic vomiting syn- cending motor weakness and decreased deep tendon drome (CVS)-like symptoms appeared after recovery reflex [1], which is known to be accompanied by au- from the autonomic neuropathy, and they improved tonomic dysfunction in 2/3 of patients [2]. The most after follow-up treatment for a few years. common symptom of dysautonomia is cardiac dys- function, while ileus, urinary retention, altered sweating, and mild hypotension are also found. The Received：May 29, 2015, Accepted：June 11, 2015 Corresponding author: Byung-Ho Choe, Department of Pediatrics, Kyungpook National University Hospital, Kyungpook National University School of Medicine, 130 Dongdeok-ro, Jung-gu, Daegu 700-721, Korea. Tel: +82-53-420-5704, Fax: +82-53-425-6683, E-mail: [email protected] Copyright ⓒ 2015 by The Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition This is an open­access article distributed under the terms of the Creative Commons Attribution Non­Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non­commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY & NUTRITION Suk Jin Hong and Byung-Ho Choe：Gastrointestinal Autonomic Neuropathy Complicated by GBS CASE REPORT lost 2 kg. Thus, he was hospitalized again in the gas- trointestinal division 1 week after discharge. At the An 8-year-old boy who was previously healthy was time of the hospitalization, he vomited whenever he treated for fever, vomiting, and diarrhea symptoms ate, and it was non-bilious. He could hardly ingest in a private clinic. He was transferred to our hospital anything orally due to his rejection of food. The pe- because of convulsions. A generalized tonic seizure diatric patient had no abnormal medical history or that lasted for about 10 min was observed. In a blood surgical history and no recent vaccinations or travel test that was performed in our hospital, the level of history. In addition, there was no abnormal family serum sodium was 115 mmol/L, which indicated a history. syndrome of inappropriate antidiuretic hormone se- His body weight was 25 kg (25th-50th percentile), cretion (SIADH). No abnormalities were observed and his height was 134 cm (90th-95th percentile). with brain magnetic resonance imaging (MRI), elec- His vital signs were as follows: 36.7oC for body tem- troencephalography, or abdominal computed tomo- perature, 90 counts/min for heart rate, 25 breaths/min graphy. Thereafter, the serum sodium value was nor- for breathing rate, and 100/60 mmHg for blood malized, and no more convulsions were observed. pressure. There was no orthostatic change. In the ab- On the 3rd day of hospitalization, the patient’s dominal examination, his bowel sounds were nor- oxygen saturation dropped to 90% during sleep, and mal, and there was no tenderness, rebound tender- fine crackles and wheezing were auscultated in both ness, or hepatosplenomegaly. There was no anemia lung fields. A chest x-ray identified infiltration in in the sclera and no abnormal heart sounds. The oral both lung fields. A blood test found an increase of the mucosa was dry. The blood test results were 4,500/mm3 mycoplasma IgM antibody titer to 10.0 (reference for leukocytes, 12.9 g/dL for hemoglobin, 293,000/mm3 range: ＜0.9 index), and the respiratory symptoms for platelets, 7.6 g/dL for serum total protein, and 4.4 improved during treatment. g/dL for albumin. Serum electrolytes, blood urea ni- The boy began to complain of pains in both legs trogen, creatinine, liver enzymes, and total choles- about a week after hospitalization, and he would not terol were unremarkable. The blood gas analysis re- walk and flopped down, even when being helped, on sults were pH 7.45, 31 mmHg for pCO2, and 22 the 13th day of hospitalization. Because a loss of the mmol/L for HCO3, urine ketones were 3+, and a thy- deep tendon reflex and peripheral neuropathy were roid function test was normal. An abdominal x-ray observed in an electromyogram and nerve con- showed no abnormalities other than constipation, duction studies, he was diagnosed with GBS. Non-spe- and an abdominal ultrasound was normal. Peristalsis cific arachnoiditis (radiculitis) was observed in spine was normal without achalasia on an esophagogram. MRI, which corresponded with the GBS. The boy An esophagogastroduodenoscopy identified reduced was treated with intravenous immunoglobulin, and antral motility. The gastric emptying half-time of he underwent rehabilitation. Thereafter, his muscle solid food was delayed to 285 min in a gastric empty- weakness symptoms gradually improved for several ing scan. weeks. Gastrointestinal motility modulating drugs, such About a month after his admission, symptoms of as low-dose erythromycin, were not effective. Vomi- voiding difficulty, dizziness during voiding and defe- ting was exacerbated, even during conservative cation, and orthostatic hypotension appeared. In ad- treatment. No improvement was observed in a fol- dition, because vomiting and constipation were also low-up gastric emptying scan. There was no prog- observed, the boy had difficulty of ingesting food. ress with the oral diet, and nutrition was therefore The symptoms waxed and waned for 2 weeks. supplied through a nasojejunal tube. Liquid food and During the follow-up examination after discharge, PediaSure were supplied through the tube, and it his vomiting was observed to be worse, and he had was replaced about every 3 weeks. Meanwhile, oral www.pghn.org 129 Pediatr Gastroenterol Hepatol Nutr lowed him to improve enough to be able to undergo oral ingestion. The hospitalization interval was ap- proximately once every few months or twice a month, and each hospitalization period was 5-10 days. During the vomiting episodes, the pediatric pa- tient exhibited very severe vomiting symptoms, and he required fluid treatment due to his inability to in- gest food. There was no accompanying abdominal pain or headache, and he did not have a migraine history or a family history of migraine. There were no prodromal symptoms, and the daily vomiting start- ing time varied from morning to night. Although it sometimes occurred after overeating or with cold symptoms that were accompanied by fever, there were many instances without abnormal causative Fig. 1. Supine anteroposterior abdominal radiograph after factors. In addition, no abnormalities were found in percutaneous endoscopic gastrostomy insertion. additional examinations, including a blood test and upper gastrointestinal series. ingestion was attempted, but it failed. Low-dose er- Because of the CVS-like symptoms, low-dose ami- ythromycin and Forlax were continued, and his triptyline was prescribed, but the child’s guardian re- body weight was maintained. fused to administer it to the patient. Because his Because the pediatric patient had difficulty with symptoms did not improve, the pediatric patient was oral ingestion due to insertion of the tube through taken to another hospital by the guardian for anoth- the nose and experienced severe psychological stress er examination. He took propranolol for a few at school, the nasojejunal tube was removed about 6 months for CVS prevention, and it had no effect. His months after its insertion. Percutaneous endoscopic body weight again decreased. The pediatric patient gastrostomy (PEG) was performed, and a tube was returned to our hospital, and he started treatment inserted into the jejunum through the gastrostomy. with low-dose amitriptyline, which resulted in Thus, nutritional support was started through the improvement. The dose was increased due to con- gastrojejunal tube (Fig. 1). After gastrojejunal tube tinuous recurrence.
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