Guillain Barré Syndrome (GBS): Unraveling the Mystery Behind it

Guillain Barré Syndrome (GBS)

Guillain Barré Syndrome (GBS) is a complex neurological disorder that can have a profound impact on an individual’s life. This comprehensive article aims to provide an in-depth understanding of GBS, covering its causes, signs and symptoms, underlying mechanisms, autoimmunity, risk factors, and the various treatment options available.

What is Guillain Barré Syndrome (GBS)?

  • Guillain-Barré syndrome (GBS) is a rare neurological disorder in which the body’s immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and sometimes paralysis. It often starts with tingling and weakness in the legs and can progress to affect the upper body and even lead to difficulties with breathing and other life-threatening complications. GBS is thought to be triggered by various factors, including viral infections and vaccinations. Early diagnosis and treatment are crucial for managing the condition and improving outcomes.

Causes of Guillain Barré Syndrome (GBS)

1 . Potential Triggers

  • Guillain-Barré syndrome (GBS) can be triggered by various factors, with infections and vaccinations being among the most commonly associated triggers:
  • Infections: GBS often follows respiratory or gastrointestinal infections caused by viruses or bacteria. Some of the infections that have been linked to GBS include:
  • Campylobacter jejuni: A bacterial infection often associated with contaminated food or water.
  • Cytomegalovirus (CMV): A member of the herpesvirus family.
  • Epstein-Barr virus (EBV): Responsible for infectious mononucleosis.
  • Zika virus: A mosquito-borne virus.
  • Influenza: The flu virus.
  • Vaccinations: While exceedingly rare, certain vaccines have been associated with an increased risk of GBS. Notable examples include:
  • Influenza vaccine: There have been sporadic reports of GBS occurring shortly after receiving the flu shot, although the risk is extremely low.
  • Swine flu (H1N1) vaccine: During the 1976 swine flu vaccination campaign, there was an elevated risk of GBS associated with the vaccine.
  • Other factors: GBS can also occur without a clear infection or vaccination trigger. In some cases, surgery or trauma has been linked to its onset.
  • It’s important to note that the risk of developing GBS due to infections or vaccinations is relatively low. The benefits of vaccination in preventing serious diseases often far outweigh the risk of GBS. If someone experiences unusual symptoms after a vaccination or infection, they should seek medical attention promptly for proper evaluation and diagnosis. Early treatment can be crucial in managing GBS and improving outcomes.
  • Molecular mimicry plays a significant role in the development of Guillain-Barré syndrome (GBS). This concept refers to a situation where components of infectious agents, such as viruses or bacteria, resemble certain structures found in the body’s own peripheral nerves.

Molecular Mimicry

  • Here’s how molecular mimicry contributes to GBS:
  • Infection Triggers Immune Response: When a person is infected with a microorganism (like Campylobacter jejuni, a common trigger for GBS), the immune system recognizes and mounts a response against the invading pathogen.
  • Cross-Reactive Antibodies: In some cases, the antibodies produced by the immune system in response to the infection can cross-react with structures on the surface of peripheral nerves. These structures may be similar in appearance or composition to components of the infectious agent.
  • Attack on Nerve Tissue: The antibodies, originally intended to target the invading microorganism, mistakenly attack the myelin sheath or other parts of the peripheral nerves due to their structural similarity. This immune response leads to inflammation and damage to the nerves.
  • Nerve Dysfunction: As a result of the immune attack, the nerves’ ability to transmit signals becomes impaired, leading to the characteristic symptoms of GBS, including muscle weakness, tingling, and, in severe cases, paralysis.
  • Molecular mimicry is one of the mechanisms through which the immune system can be triggered to attack the body’s own tissues in GBS. It highlights the complex interplay between infections, the immune response, and the development of autoimmune disorders like GBS. Understanding this process is essential for both the diagnosis and potential treatment of GBS and related conditions.

Autoimmune Response

  • In Guillain-Barré syndrome (GBS), antibodies and immune cells play a central role in damaging nerve cells, particularly the peripheral nerves. Here’s how they are involved:
  • Antibodies: Antibodies, also known as immunoglobulins, are proteins produced by the immune system to target and neutralize foreign substances, such as viruses and bacteria. In GBS, the immune system generates antibodies in response to an infection or other trigger.
  • Mistaken Targeting: However, due to a process known as molecular mimicry or other mechanisms not fully understood, some of these antibodies mistakenly recognize components of the peripheral nerves as foreign invaders. This recognition can be due to structural similarities between nerve cell components and the triggering infection or environmental factor.
  • Immune Cell Activation: Once antibodies bind to the peripheral nerve components, they activate immune cells, such as T cells and macrophages. These immune cells are mobilized to the site of the perceived threat.
  • Inflammation and Attack: Immune cells release inflammatory molecules and attack the peripheral nerves. They can damage the myelin sheath, the protective covering of nerve cells, and may even directly damage the nerve cells themselves.
  • Nerve Dysfunction: The inflammation and damage to the nerves disrupt the normal transmission of electrical signals along the nerve fibers. This disruption leads to the characteristic symptoms of GBS, including muscle weakness, tingling, and, in severe cases, paralysis.
  • It’s important to note that the immune system’s response in GBS is a misdirected attack on the body’s own tissues, known as an autoimmune response. This is different from the immune system’s typical function of defending against infections. The exact mechanisms behind why the immune system targets peripheral nerves in GBS are still an active area of research.
  • Treatment of GBS often involves interventions aimed at suppressing the abnormal immune response, such as intravenous immunoglobulin therapy or plasma exchange, to minimize nerve damage and promote recovery.

Signs and Symptoms of Guillain Barré Syndrome(GBS)

1. Muscle Weakness

  • The progressive muscle weakness in Guillain-Barré syndrome (GBS) typically follows a pattern that often starts in the legs and can spread to the upper body. This pattern is one of the hallmark features of GBS and is referred to as an ascending paralysis. Here’s a detailed explanation of how this muscle weakness typically progresses:
  • Initial Symptoms: GBS often begins with mild, non-specific symptoms that can be mistaken for a common viral illness. These initial symptoms may include fatigue, muscle aches, and numbness or tingling in the toes and feet.
  • Leg Weakness: As GBS progresses, the muscle weakness typically begins in the lower extremities, particularly in the legs. The weakness usually starts in the feet and ankles and then gradually moves upward. Patients may notice difficulty walking, standing, or lifting their legs.
  • Ascending Weakness: The term “ascending paralysis” describes the characteristic feature of GBS. This means that the muscle weakness tends to move upwards, affecting the legs first and then spreading to the upper body. The weakness can involve the thighs, hips, and trunk muscles.
  • Upper Body Involvement: In more severe cases of GBS, the muscle weakness can continue to ascend and affect the upper body. This can lead to weakness in the arms, hands, and even the muscles used for breathing and swallowing. Patients may have difficulty with tasks like lifting objects, gripping, or holding their head up.
  • Respiratory Involvement: In the most severe cases, GBS can lead to respiratory muscle weakness, which can result in breathing difficulties. Patients may require mechanical ventilation to assist with breathing if the muscles responsible for respiratory function become significantly weakened.
  • It’s important to note that the progression of muscle weakness in GBS can vary from person to person. Some individuals may experience a relatively mild form of the condition with limited muscle involvement, while others may develop more severe weakness that affects their ability to move and breathe.
  • Early diagnosis and prompt medical treatment are critical in managing GBS, as interventions such as intravenous immunoglobulin therapy or plasma exchange can help reduce the severity and duration of symptoms and prevent life-threatening complications.

2. Tingling and Numbness

  • Tingling sensations and numbness are common early symptoms experienced by individuals with Guillain-Barré syndrome (GBS). These sensory disturbances are often the first signs that something is wrong and can be quite uncomfortable. Here’s a closer look at how tingling and numbness manifest in GBS:
  • Paresthesia: The medical term for abnormal sensations like tingling and numbness is “paresthesia.” In GBS, paresthesia typically occurs in the extremities, such as the toes and fingers, but it can also affect other areas of the body.
  • Bilateral and Symmetrical: One characteristic of GBS-related paresthesia is that it often affects both sides of the body symmetrically. For example, individuals may experience tingling and numbness in both feet or both hands simultaneously.
  • Distal to Proximal Progression: Paresthesia in GBS tends to follow a pattern known as “distal to proximal progression.” This means that it usually starts in the farthest parts of the limbs (e.g., toes or fingertips) and gradually moves upward toward the trunk. This pattern is consistent with the ascending paralysis seen in GBS.
  • Sensory Nerve Involvement: GBS primarily affects the peripheral nerves, including sensory nerves responsible for transmitting sensations like touch and temperature. The immune system’s attack on these nerves can disrupt the normal signaling of sensory information, leading to abnormal sensations.
  • Loss of Sensation: As the condition progresses, the paresthesia may intensify, and numbness can set in. This means that affected individuals may lose the ability to feel touch, pain, or temperature in the affected areas. This loss of sensation can be particularly concerning if it affects the hands or feet, as it may impair daily activities.
  • It’s important to note that paresthesia is often one of the early warning signs of GBS, but it can progress to more severe muscle weakness and other neurological symptoms. Individuals who experience unexplained tingling, numbness, or weakness, especially if it appears to be spreading or getting worse, should seek immediate medical attention. Early diagnosis and treatment are essential in managing GBS and improving outcomes.

3. Loss of Reflexes

  • Guillain-Barré syndrome (GBS) can lead to a loss of reflexes, which is considered a diagnostic feature of the condition. Reflexes are involuntary, automatic responses to specific stimuli, such as tapping a tendon with a reflex hammer. The absence or significant reduction of reflexes, particularly deep tendon reflexes, is a key clinical sign that can help doctors diagnose GBS. Here’s how GBS affects reflexes:
  • Normal Reflex Function: In a healthy individual, when a tendon (e.g., the Achilles tendon in the ankle) is tapped with a reflex hammer, sensory nerve signals are generated and transmitted to the spinal cord. These signals trigger a reflex arc, causing the corresponding muscle to contract in response. This reflex action is what a doctor assesses during a physical examination.
  • GBS and Nerve Damage: GBS primarily affects the peripheral nerves, including both sensory and motor nerves. As the immune system attacks and damages these nerves, their ability to transmit signals becomes impaired. Sensory nerves are responsible for detecting stimuli, while motor nerves control muscle movement.
  • Loss of Reflexes: In GBS, the damage to peripheral nerves can disrupt the normal transmission of signals involved in reflex arcs. As a result, the reflexes become diminished or absent. This is often most noticeable in the lower limbs, where reflexes like the knee jerk (patellar reflex) and ankle jerk (Achilles reflex) may be markedly reduced or absent when tested by a healthcare professional.
  • Diagnostic Significance: The loss of reflexes, especially when combined with other neurological symptoms like muscle weakness, tingling, and sensory disturbances, is a significant clinical sign that suggests GBS. Healthcare providers use this finding, along with other diagnostic tests such as nerve conduction studies and cerebrospinal fluid analysis, to confirm a GBS diagnosis.
  • It’s important to note that the loss of reflexes in GBS is a temporary phenomenon. As the condition is treated and the damaged nerves begin to heal, reflexes often gradually return over weeks to months. Monitoring reflexes is one aspect of the clinical evaluation of GBS progression and recovery, helping healthcare providers assess the patient’s neurological status and response to treatment.

4. Pain and Sensory Changes

  • Guillain-Barré syndrome (GBS) can be accompanied by various pain and sensory changes, which can vary in intensity and location among individuals. These sensory symptoms often occur alongside muscle weakness and are part of the broader neurological manifestations of GBS. Here are some common pain and sensory changes associated with GBS:
  • Paresthesia: Paresthesia refers to abnormal sensations, such as tingling, numbness, or a “pins and needles” sensation. GBS frequently begins with paresthesia, often in the extremities like the toes and fingers. These sensations can be uncomfortable or even painful.
  • Hyperesthesia: Some individuals with GBS experience heightened sensitivity to sensory stimuli, a condition known as hyperesthesia. This means that they may perceive light touch, temperature changes, or even clothing against the skin as more intense or painful than usual.
  • Burning or Shooting Pain: GBS can cause neuropathic pain, characterized by burning, shooting, or electric shock-like pains. These pains often occur in the affected limbs and can be quite severe.
  • Achy or Cramping Pain: Muscle aches, cramps, and generalized discomfort are common in GBS. Weakness and muscle involvement can lead to a sensation of achiness or soreness in affected areas.
  • Back Pain: Some individuals with GBS experience back pain, which may be related to the inflammation of nerves in the spinal cord or the nerve roots exiting the spinal cord.
  • Loss of Temperature Sensation: GBS can affect the nerves responsible for sensing temperature. This can lead to difficulties in distinguishing between hot and cold stimuli.
  • It’s important to note that while pain and sensory changes can be distressing, they are often transient and tend to improve as GBS is treated and the nerves begin to heal. Pain management, including medications for neuropathic pain, can be a component of GBS treatment to improve the patient’s comfort.
  • If you or someone you know is experiencing symptoms suggestive of GBS, it’s crucial to seek medical attention promptly. Early diagnosis and treatment can help minimize nerve damage, manage symptoms, and improve the overall prognosis.

5. Respiratory Complications

  • Respiratory muscle weakness is a severe symptom that can occur in Guillain-Barré syndrome (GBS) and requires immediate medical attention. This symptom is particularly concerning because it can lead to difficulties with breathing and, in severe cases, respiratory failure. Here’s what you need to know about respiratory muscle weakness in GBS:
  • Involvement of Respiratory Muscles: GBS primarily affects peripheral nerves, but in some cases, the immune system’s attack on nerves can extend to the nerves that control the muscles involved in breathing. These muscles include the diaphragm and the intercostal muscles between the ribs.
  • Breathing Difficulties: When respiratory muscles become weakened or paralyzed in GBS, individuals may experience symptoms such as shortness of breath, rapid breathing, shallow breathing, and difficulty taking deep breaths. In severe cases, they may struggle to breathe at all.
  • Respiratory Failure: If respiratory muscle weakness progresses unchecked, it can lead to respiratory failure, a life-threatening condition where the individual is unable to breathe adequately to maintain oxygen levels and remove carbon dioxide from the bloodstream. This can result in a medical emergency requiring mechanical ventilation (breathing assistance using a ventilator).
  • Immediate Medical Attention: Recognizing the signs of respiratory muscle weakness is critical. These signs may include significant shortness of breath, chest discomfort, bluish discoloration of the lips or skin (cyanosis), and an inability to speak or complete full sentences due to breathlessness. If any of these symptoms occur in a person known to have GBS or suspected of having it, immediate medical attention is crucial.
  • Hospitalization and Intensive Care: Patients with GBS who develop respiratory muscle weakness are typically hospitalized and closely monitored, often in an intensive care unit (ICU). Mechanical ventilation may be necessary to support breathing until the nerves recover and muscle strength improves.
  • Prognosis: With timely intervention and appropriate medical care, many individuals with GBS-related respiratory muscle weakness can recover. However, the duration of mechanical ventilation and the overall course of recovery can vary widely among patients.
  • GBS is unpredictable, and not all individuals with the condition will develop respiratory muscle weakness. Nevertheless, it’s essential for healthcare providers and individuals with GBS to remain vigilant and prepared to address this potentially life-threatening complication promptly.

Treatment and Medications for Guillain Barré Syndrome(GBS)

1. Hospitalization and Supportive Care

  • Hospitalization and monitoring during the acute phase of Guillain-Barré syndrome (GBS) are critically important for several reasons:
  • Close Medical Observation: GBS is a rapidly evolving condition with varying degrees of severity. Hospitalization allows for close medical observation, which is essential for monitoring the progression of symptoms, identifying complications, and adjusting treatment accordingly.
  • Respiratory Support: In severe cases of GBS, individuals may develop respiratory muscle weakness, which can lead to breathing difficulties and even respiratory failure. Hospitalization enables healthcare providers to provide immediate respiratory support through mechanical ventilation, if necessary, to maintain adequate oxygen levels.
  • Preventing and Managing Complications: GBS can lead to complications such as blood clots, pressure sores, and infections. In a hospital setting, medical professionals can take proactive measures to prevent these complications and manage them effectively if they arise.
  • Administering Treatment: Intravenous immunoglobulin (IVIG) therapy and plasma exchange (plasmapheresis) are common treatments for GBS. These therapies are best administered in a controlled hospital environment, ensuring the correct dosage and monitoring for any adverse reactions.
  • Pain Management: GBS can cause significant pain, including neuropathic pain and muscle aches. Hospitalization allows for pain management through medications and other interventions to enhance the patient’s comfort and overall well-being.
  • Fluid and Electrolyte Balance: Some individuals with GBS experience difficulties with swallowing and maintaining proper hydration and nutrition. Hospitalization enables the administration of intravenous fluids and nutritional support to prevent dehydration and malnutrition.
  • Assessing Neurological Status: Healthcare providers can perform regular neurological assessments to monitor the extent of muscle weakness, sensory changes, and reflexes. This information is crucial for tracking the progression of the condition and making informed treatment decisions.
  • Safety and Mobility: GBS-related muscle weakness can increase the risk of falls and injuries. In a hospital setting, patients receive assistance with mobility, reducing the risk of accidents.
  • Psychological Support: Coping with the physical and emotional challenges of GBS can be challenging. Hospitals often have access to psychological support services to help patients and their families navigate the emotional aspects of the condition.
  • Timely Intervention: GBS is unpredictable, and its course can vary widely among individuals. Hospitalization ensures that medical interventions can be initiated promptly if the condition worsens or complications arise.
  • Overall, hospitalization provides a controlled and supportive environment for managing the acute phase of GBS, optimizing the chances of a positive outcome and reducing the risk of life-threatening complications. Early diagnosis and timely medical care are essential in managing GBS effectively.

2. Intravenous Immunoglobulin (IVIG) and Plasmapheresis

  • The two primary treatment options for Guillain-Barré syndrome (GBS) are intravenous immunoglobulin (IVIG) therapy and plasmapheresis (also known as plasma exchange). These treatments aim to reduce the severity and duration of GBS symptoms by modulating the immune response. Here’s a detailed look at each treatment option:
  • Intravenous Immunoglobulin (IVIG) Therapy:
  • Mechanism of Action: IVIG involves the administration of a high-dose infusion of immunoglobulins, which are antibodies collected from the plasma of healthy donors. These antibodies are thought to help regulate the immune system by suppressing the abnormal immune response seen in GBS.
  • Administration: IVIG is typically administered through an intravenous (IV) line over a period of several hours. The treatment is usually given daily for five consecutive days.
  • Timing: IVIG is most effective when administered early in the course of GBS, ideally within the first two weeks of symptom onset.
  • Benefits: IVIG has been shown to be effective in reducing the severity and duration of GBS symptoms. It may also shorten the time to recovery and improve overall outcomes.
  • Side Effects: IVIG is generally considered safe, but side effects can include headaches, fever, nausea, and allergic reactions. Rarely, more serious side effects may occur.
  • Plasmapheresis (Plasma Exchange):
  • Mechanism of Action: Plasmapheresis involves removing a portion of the patient’s plasma (the liquid component of blood) and replacing it with a plasma substitute or donated plasma. This process is believed to help remove harmful antibodies and other immune factors responsible for the autoimmune response in GBS.
  • Procedure: Plasmapheresis is typically performed over several sessions, with each session lasting a few hours. A special machine separates the plasma from the blood, and the remaining components are returned to the patient.
  • Timing: Plasmapheresis is often recommended for individuals with severe GBS or those who cannot tolerate IVIG. It can be initiated early in the course of the disease.
  • Benefits: Plasmapheresis can lead to a quicker improvement in symptoms and may be particularly beneficial in severe cases of GBS.
  • Side Effects: The procedure itself is generally safe, but potential side effects include a drop in blood pressure, electrolyte imbalances, and a risk of infection.
  • The choice between IVIG and plasmapheresis often depends on factors such as the patient’s condition, individual preferences, and availability. In some cases, a combination of both treatments may be used.
  • Both IVIG and plasmapheresis have been shown to be effective in managing GBS, and their primary goal is to accelerate recovery by modulating the immune system’s response and reducing the damage to peripheral nerves. Early initiation of treatment is crucial to maximize their benefits. The specific treatment plan should be discussed with a healthcare provider based on the individual’s unique circumstances.

3. PhysioTherapy and Rehabilitation

  • Physiotherapy plays a crucial role in helping patients with Guillain-Barré syndrome (GBS) recover and regain mobility. GBS often leads to muscle weakness, paralysis, and loss of coordination, making rehabilitation an essential component of the recovery process. Here’s how physical therapy benefits individuals with GBS:
  • Muscle Strengthening: GBS weakens the muscles due to damage to the peripheral nerves. Physical therapists work with patients to develop tailored exercises and strength-building routines to help rebuild muscle strength and endurance.
  • Range of Motion: Prolonged immobility can lead to joint stiffness and a reduced range of motion. Physical therapists use techniques such as stretching and passive range-of-motion exercises to prevent contractures (muscle and joint tightness) and maintain flexibility.
  • Balance and Coordination: GBS can affect coordination and balance, which can increase the risk of falls. Physical therapy includes exercises and activities that improve balance and coordination, helping patients regain their ability to stand and walk safely.
  • Walking and Mobility: Many individuals with GBS experience difficulty walking or become temporarily unable to walk. Physical therapists employ gait training techniques to help patients relearn how to walk and improve their mobility using assistive devices like walkers or braces if necessary.
  • Pain Management: GBS can cause significant pain, including neuropathic pain and muscle aches. Physical therapists can provide pain relief techniques, including manual therapy, modalities like heat or cold therapy, and education on pain management strategies.
  • Breathing Exercises: For individuals with GBS-related respiratory muscle weakness, physical therapists can teach breathing exercises to improve lung function and respiratory efficiency.
  • Functional Independence: The ultimate goal of physical therapy is to help patients regain functional independence. This includes tasks of daily living such as dressing, bathing, and getting in and out of bed or a wheelchair.
  • Patient Education: Physical therapists educate patients about their condition, exercise routines, and safety precautions. They also provide strategies for managing fatigue and preventing overexertion.
  • Progress Tracking: Physical therapists continuously assess the patient’s progress and adjust the treatment plan as needed. They set achievable goals to monitor improvements in strength, mobility, and function.
  • Psychological Support: Coping with the physical and emotional challenges of GBS can be stressful. Physical therapists often provide emotional support and motivation to help patients stay engaged in their rehabilitation.
  • Physical therapy is typically initiated once the acute phase of GBS is stabilized and medical treatment has begun. The frequency and intensity of therapy may vary depending on the severity of the condition and the individual’s response to treatment. By addressing the physical challenges associated with GBS, physical therapy plays a vital role in helping patients regain independence and improve their quality of life during the recovery process.

4. Medications for Pain and Complications

  • Several medications may be prescribed for pain relief and symptom management in individuals with Guillain-Barré syndrome (GBS). The choice of medication depends on the specific symptoms and needs of the patient. Here are some common medications used for pain relief and symptom management in GBS:
  • Pain Medications:
  • Over-the-Counter (OTC) Pain Relievers: Non-prescription pain relievers like acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil) may be used to manage mild to moderate pain.
  • Prescription Pain Medications: In cases of severe pain, especially neuropathic pain, healthcare providers may prescribe stronger pain medications like opioids (e.g., morphine, oxycodone). However, opioids are typically used cautiously due to their potential for dependence and side effects.
  • Neuropathic Pain Medications:
  • Gabapentin (Neurontin) and Pregabalin (Lyrica): These medications are often prescribed to manage neuropathic pain, which is common in GBS. They work by calming overactive nerves and reducing pain.
  • Tricyclic Antidepressants: Medications like amitriptyline or nortriptyline are sometimes used to manage neuropathic pain. They can help block pain signals and improve sleep, which can be disrupted in GBS.
  • Anticonvulsants: Certain anticonvulsant medications, such as carbamazepine or phenytoin, may be considered for pain management in GBS.
  • Muscle Relaxants:
  • Baclofen: Baclofen is a muscle relaxant that may be prescribed to reduce muscle spasms and improve muscle function in individuals with GBS.
  • Anti-Anxiety Medications:
  • Benzodiazepines: Medications like lorazepam or diazepam may be prescribed to manage anxiety, particularly in cases where individuals are experiencing significant stress or difficulty sleeping.
  • Immunomodulatory Therapies:
  • Intravenous Immunoglobulin (IVIG): While IVIG is primarily used to modify the immune response in GBS, it can also provide some relief from certain symptoms, including pain.
  • It’s essential for healthcare providers to carefully assess the patient’s symptoms and individual needs when selecting medications. Medications for pain management should be used judiciously, and their benefits should outweigh potential side effects and risks.
  • Additionally, the use of medications is often combined with other forms of therapy and support, such as physical therapy and psychological support, to provide a comprehensive approach to symptom management and overall care for individuals with GBS.

Dr Suraj M

1 Response

Leave a Reply

Your email address will not be published. Required fields are marked *

Post comment