Atpical Guillain–Barré Syndrome - Bilateral sixth nerve palsy and bilateral facial palsy with ascending upper extremity and descending lower extremity paralysis, a rare entity

Background: Guillain–Barré syndrome (GBS) is an acute immune-mediated polyneuropathies, which has many typical and atypical clinical presentations. The original description of “ascending paralysis” is the most commonly observed variant. Atpical GBS is a heterogenous disorder with various atypical features. Case report: We report a case of 30 year old male with acute onset of double vision and is more when looking far away. This was followed with deviation of angle of mouth towards right side followed by other side involvement This was followed by slurred speech and increasing upper extremity weakness that had progressed to proximal lower extremities, with no significant past medical history.Neurological examination showed bilateral sixth nerve palsy with bilateral seventh nerve palsy, symmetrical upper greater than lower limb weakness with absent deep tendon reflexes. There was no respiratory or bulbar muscle involvement. NCS examination revealed demyelinating polyradiculopathy. Cerebrospinal fluid examination was suggestive of albumin-cytological dissociation supporting GBS. MRI brain and orbit with contrast imaging showed no abnormalities. MRI cervical spine with screening of rest of spine showed no abnormalities. Diagnosis of a rare atypical GBS was clinically made. Patient was started on immunoglobins. Patient responded to treatment. Conclusion: Atypical presentation of GBS may delay diagnosis and treatment. Diagnosis can be confirmed by comprehensive clinical examination, followed by nerve conduction tests and CSF analysis. Objective of this case is to highlight rare and atypical clinical presentation of GBS, which can cause delay in diagnosis and further management