Case report Albumin levels as a biomarker for second Intravenous Immunoglobulin (IVIG) treatment in Guillain-Barre syndrome (GBS) Anna Shalman a,1 , Shiri Savir a,⇑,1 , Yana Mechnik Steen b , Andrey Ovanyan b , Nancy Boniel c , Leonid Koyfman a , Yoav Bichovsky a , Alexander Zlotnik a , Moti Klein a , Evgeni Brotfain a a Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel b Department of Neurology Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel c Department of Radiology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel article info Article history: Received 2 November 2019 Accepted 12 January 2020 Available online xxxx Keywords: Guillain-Barre Syndrome Intravenous Immunoglobulin Serum albumin Hypoalbuminemia abstract Background: Patients with GBS may develop hypoalbuminemia following treatment with Intravenous Immunoglobulin (IVIG), which is related to a poorer outcome. This report presents a patient with GBS and his clinical response to two courses of IVIG treatments in association with his albumin level. Case report: A previously healthy 21-year-old male was admitted to the GICU due to GBS with severity grade 5 (required assisted ventilation). IVIG treatment was initiated. Over the next two weeks there was no clinical improvement and Albumin level dropped from 4.5 gr/dL to a nadir of 2.3 gr/dL. A second course of IVIG was initiated. After initiation of the second course the patient’s albumin began rising to 3.0 gr/dL and a clinical improvement followed this rise. Subsequently, he was weaned from mechanical ventilation within a few days. Conclusions: When considering a second course of IVIG treatment, serum albumin levels may be consid- ered a biomarker as part of the decision algorithm. Ó 2020 Elsevier Ltd. All rights reserved. 1. Introduction Guillain-Barré syndrome (GBS) is an acute inflammatory disor- der of the peripheral nervous system. The severe, generalized man- ifestation of GBS with respiratory failure that requires mechanical ventilation affects around 30% of cases [1]. Several randomized controlled trials studying the effect of immunotherapy in GBS have been done in the past few decades [2,3]. Treatment of choice is supportive care, in addition to either IVIG or plasma exchange – both of which have been proven effective [2,3]. Recent literature suggests that there is a prognostic value for serum albumin levels regarding the outcome in patients with GBS. According to van Kon- ingsveld et al. [4], low albumin levels correspond with a poor clin- ical outcome, whereas high levels correspond with a better outcome. Some of the more severely affected patients with GBS may benefit from an additional course of IVIG therapy (2 g IVIg/ kg in 2–5 days), and this is currently being studied in an ongoing randomized clinical trial in Netherlands (SID-GBS RCT trial) [5]. In the SID-GBS trial, prognosis is defined using the modified Eras- mus GBS outcome scale (mEGOS) which includes the poor prog- nostic factors: age > 55, preceding diarrheal illness and low medical research council (MRC) scale sum-score [6,7]. To date, no RCTs have proven the benefit of an additional course of IVIG in sev- ere cases. Nevertheless, repeated treatments have been observed to be beneficial in some patients with severe disease and it is com- mon practice in many centers [8]. This report presents a patient with GBS and his clinical response to two courses of IVIG treat- ments in association to his albumin level. 2. Case report A previously healthy 21-year-old male was admitted to the ER with a 5-day history of proximal lower limb weakness along with complaints of back pain. There was no history of fever, diarrhea, rinorrhea or cough in the month prior to admission. On examina- tion, the patient was alert and oriented, and denied dyspnea. Car- diac and respiratory examinations were normal. Neurologic examinations revealed absent tendon reflexes in both the upper and lower limbs. The muscles of upper and lower limbs showed bilateral weakness (3/5 upper limb, 2/5 lower limb), and pain https://doi.org/10.1016/j.jocn.2020.01.067 0967-5868/Ó 2020 Elsevier Ltd. All rights reserved. ⇑ Corresponding author at: Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center P.O. box 151, Beer-Sheva 84101, Israel. E-mail addresses: yona.shiri@gmail.com (S. Savir), yaname@clalit.org.il (Y. Mechnik Steen), andreyov@clalit.org.il (A. Ovanyan), motik@clalit.org.il (M. Klein). 1 Dr Shalman and Dr Savir are equally contributed in this paper. Journal of Clinical Neuroscience xxx (xxxx) xxx Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn Please cite this article as: A. Shalman, S. Savir, Y. Mechnik Steen et al., Albumin levels as a biomarker for second Intravenous Immunoglobulin (IVIG) treat- ment in Guillain-Barre syndrome (GBS), Journal of Clinical Neuroscience, https://doi.org/10.1016/j.jocn.2020.01.067