In Nepal many neurological diseases go undiagnosed. This is because the field of neurology is complicated and difficult to comprehend. Furthermore we do not have enough neurologists to make a proper diagnosis. Many people get neurologists and neurosurgeons mixed up. The neurologist unlike the surgeon is not involved in operating on the patient. What he does is takes a careful history and examines the patient and after a good bit of thinking and diagnostic tests arrives at a conclusion about what is ailing the patient. If there is surgery needed then the patient is referred to the neurosurgeon. Most epilepsy, parkinsonism, and migraine headaches are some of the most common problem that a neurologist will encounter in his or her daily practice that usually does not require the help of a neurosurgeon. Another relatively common neurological problem  is Guillain Barre ( GB) syndrome that a competent general internist or a neurologist can effectively deal with. 


In June 2011 there were reports of patients from Yuma County, Arizona, USA with  GB Syndrome.  This syndrome is very well known to Nepali doctors, partly because of its close association with gastroenteritis ( diarrhea), a common problem in Nepal.  In the neighborhood of Yuma County there had been an outbreak of diarrhea caused by a bacteria called Campylobacter Jejuni, the commonly implicated bacteria in immunologically triggering GB syndrome after a few days to weeks.


Campylobacter bacteria is one of the well-known causes of diarrhea in Nepal, and so it is not surprising that GB syndrome which presents with weakness of the legs ( picture) is seen in Nepal. It is important to emphasize that only a small minority of patients with Campylobacter gastroenteritis suffer from GB syndrome.  Obviously if we kept meticulous notes and had proper disease surveillance in place, we would indeed be able to pick up GB syndrome cases and possibly trace them to gastroenteritis outbreaks.


The weakness in both the legs can slowly creep up to the chest and face. In the chest the weakness may interfere with breathing, and hence GB syndrome patients need close monitoring. Most patients make a good recovery, but this may take months.   Steroids are often prescribed, but they are useless. There are two modes of treatment: Plasmapharesis entails removal of the troublesome antibodies in the plasma by means of an especial machine. Intravenous immunoglobulin administration is the other therapeutic modality. Both are very effective, expensive, and seldom available here.  However the main thing regardless of the availability of these therapies is to make sure that the patient has ventilator support if the need should arise as just competently dealing with the symptoms is often good enough.  However, ventilators are not available in many areas of Nepal. 


So prevention of GB syndrome becomes paramount which means avoiding diarrhea even though not all  GB syndrome needs a trigger like campylobacter- induced diarrhea. (Indeed GB syndrome can happen spontaneously, but there are reports that patients with the GB syndrome associated with campylobacter have a worse prognosis ).  Washing hands with soap and water, drinking boiled water, treating salad with chlorine or iodine tablets dissolved in water before consumption, and avoiding restaurant food cooked the previous day and kept without  refrigeration ( what with power cuts!)  become crucial in the context of Nepal to try to try to avoid even that small chance of acquiring the GB Syndrome.