J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.11.983 on 1 November 1981. Downloaded from http://jnnp.bmj.

com/ on 27 September 2018 by

Journial of Neurology, Neurosurgery, anid Psychiatry 1981:44:983-990

Autonomic dysfunction in Guillain-Barre syndrome

RR TUCK, JG McLEOD
From the Department of Medicine, the University of Sydney, and the Department of Neurology, The Roval
Prince Alfred Hospital, Camperdown, NSW, Australia

SUMMARY The following tests of autonomic function were performed on seven patients with the
Guillain-Barre syndrome and compared with controls: (1) measurement of heart rate and blood
pressure in the supine and erect positions, (2) measurement of baroreflex sensitivity, (3) Valsalva's
manoeuvre, (4) sweat test. In two patients the heart rates were fixed and greater than 100/min and in
three there was postural hypotension. The baroflex sensitivity of four patients was abnormal and
heart rate response to Valsalva's manoeuvre was impaired in two of the three patients who were
able to perform the manoeuvre. Areas of anhidrosis were found in all seven patients. These abnorm-
alities probably reflect pathological alterations of the sympathetic and parasympathetic components
of the autonomic nervous system of patients with Guillain-Barre syndrome. The severity of autonomic
involvement is not related to the degree of sensory and motor disturbance which is consistent with the

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patchy distribution of lesions throughout the peripheral and autonomic nervous systems.

Autonomic dysfunction may occur in the Guillain- Control subjects

Barre syndrome and account for some of the The control subjects were five healthy males whose ages
fatalities in the condition. Manifestations of ranged from 20 to 49 years (mean 38; SD 8). They were
autonomic involvement are disturbances of sweat- free of hypertension, heart disease and neurological
ing,' heart rate and rhythm,2 3 blood pressure disease and were taking no medication.
control,3-6 and sphincter, visceral and pupillary Patients
function.' 6 The ages of seven patients (five males, two females) with
The baroreceptor-heart rate reflex has not pre- Guillain-Barre syndrome ranged from 33 to 55 years
viously been studied in a group of patients with (mean 43; SD 9). None suffered from hypertension or
Guillain-Barre syndrome, as it has been in patients heart disease. The interval between the onset of weakness
with peripheral neuropathy due to diabetes, alcohol and the time of maximum disability ranged from 12 hours
and porphyria.7-9 In view of the potentially fatal to three weeks. Six patients had a presumed viral illness
disturbances of autonomic function that can occur in at an interval ranging from three days to seven weeks
the Guillain-Barre syndrome, it seemed appropriate before the onset of neurological symptons. The patients
to investigate the abnormalities of sweating and disability at the time of testing was graded on a scale from
0 to 5 (table 1). None of the patients required assisted
baroflex control of heart rate and blood pressure in ventilation. In five patients, the CSF protein concen-
patients with this condition. A brief account of this tration was greater than 04 g/l. Abnormalities of
study has already been published.10 peripheral nerve conduction were demonstrated in all
patients. Serum B12, serum folate and glucose tolerance
Materials and methods
Tests of autonomic function were performed on five Table I Disability status of patients with GBS at time
healthy subjects and seven patients with Guillain-Barre of autonomic testing
syndrome after informed consent had been obtained.
Status Criteria
O Normal
Address for reprint requests: J G McLeod, Departnment of I Symptoms but no signs
Medicine, The University of Sydney, Sydney, New South 2 Mild motor and sensory symptoms andl signs
Wales 2006, Australia. 3 Moderate disability
4 Assistance needed with walking
5 Unable to walk
Accepted 21 July 1981
983
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.11.983 on 1 November 1981. Downloaded from http://jnnp.bmj.com/ on 27 September 2018 by
984 Tuck, McLeod
tests were normal and urinary porphyrins were not successive manoeuvres. Approximately two minutes
detected. were allowed between each. The Valsalva ratio was calcu-
The interval between the onset of weakness and the lated by dividing the longest heart period occurring after
autonomic tests ranged from one to nine weeks. Three the manoeuvre by the shortest during the manoeuvre.12
patients were being treated with oral corticosteroids at The highest ratio from the three attempts was recorded.7
the time of the investigations; one patient (Case 5) was
receiving amitriptyline 75 mg at night and diazepam The sweat test
15 mg/day, but no other patient was being treated with Sweating was assessed by mapping the areas of skin
drugs which affected autonomic function. which sweated in response to body heating. Each subject
lay supine while a powder (alizarine red 35 G, rice starch
Measurement of heart rate and heart period 60 G and sodium carbonate 20 G) that changed colour
Heart rate and heart period (R-R interval) were measured from pale pink to deep purple when wet was dusted over
from the patients' electrocardiogram with a Grass EKG all of the visible skin surface except the face. A heating
Tachograph preamplifier (Model 7P4D) and recorded cradle was placed over the subject's chest and abdomen
using a Grass (Model 7B) pen recorder. and heat was applied until oral temperature had risen
I C or until sweating began to occur on the face when the
Measurement of arterial blood pressure areas over which sweating occurred were recorded.
The arterial blood pressure was measured through
a cannula inserted into the left brachial artery using Statistical methods
a pressure transducer (Statham Model P23AC) placed at Means are expressed with standard deviations and were
the approximate level of the aortic valve, a Grass (Model compared using the two-tailed Student's t test.13 The
7P1B) preamplifier and Model 7DAE driver amplifier sample variances were compared using the Variance
and was recorded on another channel of the pen recorder. Ratio Test (Snedecor's 'F' test). If there was a significant
difference between variances (p < 0-05) the means were
Alteration of posture

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compared using t', instead of t.13 Data which differed by
The subjects lay quietly on a tilt table until the pulse and more than two standard deviations from the control mean
blood pressure remained steady. The subjects and patients were regarded as abnormal. The data relating heart
were then tilted until either they were vertical or their period and systolic blood pressure were stored on paper
systolic blood pressure fell below 90 mmHg. Except when tape. The linear regressions of the heart period and blood
postural hypotension was severe, subjects were tilted for pressure were calculated with the aid of a PDP 11/40
five minutes before being returned to the horizontal computer using the method of least squares.13 The
position. Heart rate and blood pressure during tilting significance of the regression coefficient was calculated.'3
were recorded continuously.
Measurement of baroreceptor-heart-rate reflex
Results
sensitivity
The sensitivity of the baroreceptor-heart rate reflex was The disability status of the seven patients with
measured by comparing changes in the heart period with Guillain-Barre syndrome and the individual
changes in systolic blood pressure. Transient elevations of pooled results of autonomic function tests performed
arterial blood pressure were produced with intravenous on the five control subjects and the seven patients
injections of phenylephrine, an alpha-adrenergic agent are shown in Table 2.
that raises blood pressure by causing peripheral vaso-
constriction while having little direct effect on heart rate. HEART RATE
The drug was given intraveneously over 10-30 seconds in The resting heart rates of five control subjects ranged
doses ranging from 25-300,g. Up to six injections were from 57 to 68 beats/min (mean 64 ± 4). Heart rates
given to each subject, at least two minutes being allowed of the seven patients ranged from 73 to 118 beats/min
between each injection. The baroflex sensitivity was
calculated according to the method described by Smyth (mean 92 ± 16). The differences are significant
et al.11 Each heart period was plotted against the systolic (p < 002). In two patients (Cases 1 and 5) the
blood pressure of the preceding heart beat from the start resting pulse rates were greater than 100/minute.
of the rise in blood pressure to the peak, and the slope of
the linear regression of these points so obtained was used BLOOD PRESSURE
as an estimate of baroreflex sensitivity (ms/mmHg). The resting arterial blood pressures of the five
control subjects ranged from 115/65 to 160/95 mmHg
Valsava's manoeuvre (mean 132/77 ± 19/12). The resting arterial pressures
The manoeuvre was performed with the subjects on the in the seven patients, none of whom were known to
tilt table elevated to an angle of 300. The subjects were
asked to maintain a column of mercury in a manometer be hypertensive prior to their illness, ranged from
at a height of 40 mm for ten seconds using a mouthpiece 122/66 to 175/92 (mean 153/87 + 21/14). There was
which consisted of a syringe barrel. After several trial no significant difference in the mean systolic or
attempts the heart period and blood pressure were diastolic blood pressures in the two groups, although
recorded before, during and 30 seconds after three in Cases I and 7 systolic blood pressures were
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Autonomic dysfunction in Guillain-Barre syndrome 985
Table 2 Summary ofresults of autolnioic tests performed on five healthy subjects and seven patients with GBS
ANumtiber Age Sex DisabilitY Tiineftronz Heart rate In(rease Arterial blood pressuee Va/salva Baroreflex
status oniset of Supilie Erect % Supine Erect Change ratio sensitivity
GBS to (beats/mninute) nnzHg minnHg °' tis/lnmHg
(/ate of
tests (dlay)
125 118S -5 6 2-4 15
Control 1. 34 M 0 - 57 77 35
12
15 75
subjects 160 155 -3.1 2-3 14
2. 45 M 0 - 63 71 13 95 98 32
115 112 -2-6 229 9.1
3. 34 M 0 - 67 893 33 65 70 - 77
118 110 -6-8 2-1 6-3
4. 49 M 0 - 65 73 12 73 68 -69
140 130 -7-1 27 11
5. 293 M 0 - 68 85 25 83 80 -3 6
Mean 38 132 125
- - - 64 79 24 -[6 r-084;n =29
19 18 -1 0 r3-
SD 8 - - - 4 8 11 12 12 65
Patients 1. 48 F 5 30 118 120 1-7 92 90 -2
2 016
135 130 -3-7 2-9 17
2. 35 M 2 20 83 100 21 77 73 -5-2
3. 44 M 5 32 88 112 27 66 66 -0- 1-5 56
140 136 -2-9 1-7 8-4
4. 54 M 5 17 83 9)2 11 75 71 -53

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168 100 -41 - 0-41
5. 55 F 5 63 1 10 1 12 1-8 ,98 65 -34
155 112 -28 - 3-0
6. 33 M 2 13 86 104 21 loo 65 -35
173 121 -30 - 5-1
7. 32 M.i 5 7 73 95 30 100 80 - 20
Mean 43 - - - 92 105 16 87 123 -14 50;2n-0542
r 0
10 12
21
14 18
98 IS15 - -
SD 10 - - - 16
p >005 <0 02 >005 --005 -0-05 <001
0-05 0-05

(*Slope of regression of pooled dat..)

abnormal (table 2). In one patient (Case 5), the blood increased in two of the control subjects when tilted,
pressure fluctuated during the course of the illness the mean change being -1 6% (±6 5%). The
to levels as high as 230/120. diastolic blood pressure fell on tilting in six of the
patients and remained unchanged in the seventh.
EFFECT OF POSTURE ON HEART RATE AND The mean change was - 14 % ( ± 15 %) which was not
BLOOD PRESSURE significantly different from the control mean but in
The heart rate was measured immediately before Cases 5, 6 and 6 the fall in diastolic blood pressure
tilting and as soon as tilting was complete. The mean was abnormal.
increase in control subjects was 240% (± 11 %) and in The changes in heart rate and the blood pressure
patients it was 16 % ( ± 12 %). There was no significant responses to tilting in a control subject and in two
difference in the two groups, although in Cases I patients are shown in fig 1.
and 5 the heart rate increased only 1-7% and 1.80%
respectively, both of which are abnormal. BAROFLEX SENSITIVITY
The systolic blood pressures of all control subjects The range of sensitivity of the baroreceptor-heart-
fell slightly on tilting, the mean fall being rate reflex was 6-3 to 15 ms/mmHg in five control
50 (± 2 1 %). The mean fall in the systolic blood subjects (mean 12 ms/mmHg; r = 0-84; N = 29).
pressure of patients was 18 % ( ± 15 %) which did not In the seven patients the range of baroreflex sensi-
differ significantly from the control mean. In all tivity was 0 16 to 17 ms/mmHg; r = 0 50; n = 42).
patients the systolic blood pressure fell on tilting The difference was significant (p < 0-01) (figs 2 and
and in Cases 1, 5, 6 and 7 the percentage fall was 3). When the data for each patient were compared
abnormal. with the pooled control data, the baroreflex sensi-
The diastolic blood pressures fell in three and tivities of Cases 2, 3 and 4 did not differ significantly
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.11.983 on 1 November 1981. Downloaded from http://jnnp.bmj.com/ on 27 September 2018 by
986 Tuck, McLeod
Control
4001
A 90]
BP 12i n_ E1
75_
300-
1001 .0
HR70 ' /-J p ~ V

200-

BP
150
90

50-
Case 5
a 10
S
O-
A
HR 120i
100
0 5 10 15 20 25
Case 6 Increase in systolic blood pressure (mmHg)
A 90]
0 Fig 2 The relationship between the increase in he(alt
150 1 per-iod and the incr ease in systolic blood pressur e
BP_ following intravenous injections of phenylephrine. The

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50- closed circles represent the means of the pooled data
from the 5 control subjects and the open circles r-epresent
R100] the means of the pooled data from the 7 patients with
HR 8]<---
GBS. Vertical bars epresent + I SE. The slopes of the
r-egression lines are 12 ms/mmHg for the control subjects
1 minute (r = 0-84, n - 29) and 5-7 (ms/mmHg) for the patients
with GBS (r 0 50, n = 42). The difference between
Fig I Records obtainedfrom one control subject and the slopes was significant (p < 0-01).
tvo patients with GBS (Cases 5, 6) showing the changes
in heart-rate and blood pressure in response to tiltinig.
Postural hypotension is pr-esent in both patients and in
Case 5, the heart-r-ate is fixed at 110 per minute (A
angle of tilt; BP =-- arterial blood pressure, mtnnHg; blood pressure (Phase III). The blood pressure then
HR = heart rate, beats/minute). rapidly increased to a level above the resting value
to which it returned over the subsequent 15-40
seconds (Phase IV). The mean ratio of the shortest
R-R interval (Valsalva ratio) was 2 5 + 0-3).
from the control sensitivity. The sensitivity was Facial and respiratory weakness prevented four
significantly less than the control value in Case 7 patients from performing Valsalva's manoeuvre. In
(p < 0 05) and in Cases 1, 5 and 6 (p < 0-01). Two the other three the blood pressure changes during
of the patients (Cases I and 5) had baroreflex and after the manoeuvre were normal. In Case 2 the
sensitivities of only 016 and 0-41 ms/mmHg, Valsalva ratio was in the control range while in
respectively (fig 3). Thus, their heart rates remained Cases 3 and 4 the ratios were 1-5 and 1-7 which were
almost unchanged despite increases of up to below the normal range.
30 mmHg in systolic blood pressure. Both of these
patients had fast resting heart-rates (.1 18 and SWEAT TEST
110 beats/min respectively) and one (Case 5) had A sweat test was attempted on all seven patients.
postural hypotension. One patient (Case 5) was unable to tolerate the test
but she had not demonstrated any signs of sweating
VALSALVA'S MANOEUVRE after her oral temperature had risen from 35 8° to
When the five healthy subjects performed Valsalva's 36-4 OC. The other six patients were all able to tolerate
manoeuvre there was an initial transient increase in heating, and all had some areas of anhidrosis
the arterial blood pressure (Phase I) which then fell (fig 4). Two patients (Cases 3 and 7) had complete
to a level less than the resting value at which it anhidrosis of the lower limbs and three patients
remained until forced expiration ceased (Phase It). (Cases 1, 3 and 6) had areas of anhidrosis on their
At that moment, there was a transient fall in arterial abdominal walls.
 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.11.983 on 1 November 1981. Downloaded from http://jnnp.bmj.com/ on 27 September 2018 by
Autonomic dysfunction in Guillain-Barre syndromne 987
Controls GBS
2 3
0

0
15
0 F f 4- 4,+ C Ad
I

1% p II
0
Baroref lex sensitivity
(ms/mmHg) 10

0~~ I..-I 1)

0 4
Sq

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.I

0J X -

Fig 3 The baroreflex sensitivities of 5 healthy subjects

anid 7 patients with GBS. The baroreflexv sensitivity of
the control group was 12 ms/mmHg (r = 0-84, n = 29)
and of the patient group was 5 7 ms!mmHg (r = 0 50,
n = 42). The difference between the two sensitivities was Fig 4 Patterns of sweat production in 6 patients with
significant (p < 0-01). GBS. Black areas indicate regions of normal sweat
production while the spotted areas are those in which
sweating was patchY.
Discussion
The results of the present investigation have shown cases 1 and 7 supine systolic blood pressures were
that in patients with Guillain-Barre syndrome there greater than two standard deviations above the
are abnormalities of control of heart rate, blood control mean and in Case 5 the blood pressure
pressure and sweating. Although only five control fluctuated considerably during the course of the
subjects were studied in detail, the values obtained illness reaching levels as high as 230/130. Elevated or
were similar to those of other workers for the mean fluctuating arterial blood pressure has been docu-
resting heart rate7 14 and change in heart rate'5 and mented previously in Guillain-Barre syndromel 2 5
blood pressure with tilt.16 The increased mean resting and may be caused by lesions of the glossopharyngeal
heart rate in the seven patients, in two of whom nerves which contain afferent fibres from the arterial
(Cases 1 and 5) it remained relatively fixed through- baroreceptors. The hypothesis that lesions of the
out the study at greater than 100/minute, is consistent afferent nerves from arterial baroreceptors are
with the observations of previous investigators who responsible for hypertension, fluctuating arterial
noted tachycardia in this condition.1-3 Increased blood pressure and tachycardia is consistent with
resting heart rates have been observed in patients studies on experimental animals and human sub-
with diabetes mellitus7 and acute intermittent jects with lesions of these nerves.19-2' It is significant
porphyria.17 In both these conditions the tachycardia that the patient who had fluctuating arterial blood
has been attributed to lesions of the vagus or pressure and tachycardia (Case 5) had left-sided
glossopharyngeal nerves or both.'7 18 A fixed palatal weakness, dysphagia and dysphonia, clinical
tachycardia also occurs when the autonomic nerve features that are consistent with a lesion of the left
supply to the heart is blocked pharmacologically.15 vagus nerve.
Therefore, it is likely that the relatively fixed rapid A significant fall in both the systolic and diastolic
heart rate of Cases 1 and 5 was a result of involve- arterial blood pressures occurred on tilting three of
ment of the cardiac autonomic nerve supply. In the seven patients with Guillain-Barre syndrome.
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988 Tuck, McLeod
Orthostatic hypotension has been found in patients rapid changes in heart rate which are mediated
with Guillain-Barre syndrome by other investi- largely by the parasympathetic nervous system in
gatorsl 45 and is also a common finding in patients response to changes in arterial pressure." 14 23 The
with diabetic autonomic neuropathy.7 It does not method has been used to demonstrate impairment
normally occur in healthy subjects because of the of baroreflex sensitivity in patients with diabetic
control of arterial blood pressure by the baroreflexes. neuropathy.29 It is simpler than that devised by
On assuming the upright position there is an increase Korner et al,14 which measures the steady state
in splanchnic vascular resistance which contributes characteristics of the baroreflex and which has been
substantially to the overall vascular resistance.22 used previously in our laboratory.7 8 Lesions in the
The decrease in splanchnic blood flow is attributed to afferent nerve fibres in the glossopharyngeal and
arteriolar constriction which is mediated by the vagus nerves from the carotid sinus and aortic arch
sympathetic nervous system.23 It has been shown by baroreceptors and/or efferent fibres in the vagus
direct intraneural recording of sympathetic nervous nerves may reduce the sensitivity of the baroreflex
activity from muscle nerves in man that changing which was found in four of the patients in the present
position from supine to sitting or standing increases study and in the patient of Davidson and Jellinek.28
muscle sympathetic nerve activity.24 The veins may The glossopharyngeal and vagus nerves are known to
also play some part in maintaining arterial blood be affected both clinically6 and pathologically30 in
pressure in the upright position.25 The distensibility Guillain-Barre syndrome although in the present
of superficial veins decreases in normal subjects study only one (Case 5) of the four patients with an
during the performance of Valsalva's manoeuvre26 abnormal baroreceptor heart rate reflex had obvious
but in some patients with Guillain-Barre syndrome clinical evidence of involvement of these cranial
this response has been found to be absent presumably nerves.

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due to involvement of their sympathetic nerve Impaired function of the baroreflexes could be due
supply.27 The postural hypotension of patients in the to a lesion or lesions in the vasomotor centres of the
present study was probably related to lesions of the medulla. This explanation is unlikely in a disease of
sympathetic nervous supply to the arterioles and the peripheral nervous system in which pathological
veins or of the afferent fibres from the arterial changes within the brainstem are usually minimal or
baroreceptors. Of the three patients in the present absent.3 30 However, extensive changes in the brain-
study with marked orthostatic hypotension, there stem involving the vagal nuclei have been described3l
was evidence in two (Cases 6 and 7) that the baro- and physiological studies32 provide some evidence
receptor afferent fibres were partially intact because that central autonomic pathways maybe involved.
the changes in their heart rate with increases in blood None of the patients in the present study suffered
pressure were qualitatively normal. The third patient from heart disease and the only ECG abnormality
with postural hypotension (Case 5) had a fixed heart was sinus tachycardia. However, pathological
rate as well as severe postural hypotension which changes have been found in the hearts of some
may have been caused by lesions of the sympathetic patients who died with Guillain-Barre syndrome3
and vagus nerves on the efferent side of the baro- although Bredin2 could find no abnormalities in the
reflex arc and/or lesions of the afferent fibres from hearts of two patients who died apparently as a result
the baroreceptors. In this patient there was clinical of cardiac complications of the syndrome.
evidence of involvement of one vagus nerve in which Abnormalities of the heart rate and blood pressure
afferent fibres from the aortic arch baroreceptors and responses to Valsalva's manoeuvre have been
efferent fibres to the heart could also have been reported in Guillain-Barre syndrome,5 27 but the
affected. However from the present study it is three patients in the present study who were able to
impossible to determine exactly the site of the perform the manoeuvre had normal responses,
autonomic lesions. The absence of postural hypo- although in two, the Valsalva ratio was below the
tension in one (Case 1) of the two patients who had control range of the present study. None of the three
a resting tachycardia is evidence that the baro- patients had orthostatic hypotension or abnormal
receptor afferent and sympathetic efferent fibres were baroreflex sensitivities and it was concluded that they
intact but that the vagal efferent fibres to the heart had minimal disturbance of reflex autonomic
were affected. cardiovascular control. It is probable that the patients
The sensitivity of the heart-rate-baroreceptor with postural hypotension and impaired baroreflex
reflex was measured in one patient with Guillain- sensitivities would have had an abnormal Valsalva
Barre syndrome by Davidson and Jellinek28 but the response if they had been able to perform the
present study is the first in which changes in the manoeuvre.
sensitivity of the reflex have been documented in The sweat test was abnormal in six patients in
a group of such patients. The method used measures whom it was performed satisfactorily. Absent or
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Aiutoniomic dvflitnion iti Guillci,i-Barre sYndrome 989
impaired sweating was found on the abdominal wall from absent circulatory reflexes. Lancet 1963;1:
of three patients-two of whom had postural 1121-6.
hypotension (Cases 6 and 7). Since surgical resection 5Birchfield RI, Shaw CM. Postural hypotension in the
of the lower thoracic sympathetic ganglia and Guillain-Barre syndrome. Ar-ch Neurol 1964;10:
splanchnic nerves cause postural hypotension33 and 149-57.
6 Marshall J. The Landry-Guillain-Barre syndrome.
anhidrosis of the abdominal wall,34 it is suggested Brain 1963;86:55-66.
that the anhidrosis and postural hypotension in Low PA, Walsh JC, Huang CY, McLeod JG. The
Cases 6 and 7 was due to involvement of the lower sympathetic nervous system in diabetic neuropathy-
thoracic and upper lumbar segments of the sym- a clinical and pathological study. Br-ain 1975 ;98:
pathetic chains or splanchnic nerves or both. Postural 341-56.
hypotension in patients with diabetes mellitus has 'Low PA, Walsh JC, Huang CY, McLeod JG. The
been attributed in part to pathological changes that sympathetic nervous system in alcoholic neuropathy
occur in the greater splanchnic nerves.7 -a clinical and pathological study. Brain 1975;
The present investigations have demonstrated 98:357-64.
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porphyria complicated by severe autonomic neuro-
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glossopharyngeal nerves, in the efferent para- 1978 ;15 :197-203.
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studies have demonstrated demyelinating lesions in Circ Res 1969;24:109-21.
the glossopharyngeal and vagus nerves30 31 and in 12 Levin AB. A simple test of cardiac function based upon
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