Early Sensory-Predominant Guillain-Barré Syndrome With Normal Cerebrospinal Fluid and MRI Findings: A Diagnostic Challenge

Sep 29, 2026

Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that usually follows an infection and presents with progressive, symmetric weakness and areflexia. Early or atypical cases may lack classical findings, including elevated cerebrospinal fluid (CSF) protein or abnormal magnetic resonance imaging (MRI), making diagnosis difficult. A 46-year-old woman developed distal paresthesias, gait instability, perioral numbness, hoarseness, and later right foot-drop after a viral-like illness. Despite normal CSF protein and unremarkable brain and spine MRI with preserved strength, the clinical picture suggested early sensory-predominant GBS; intravenous immunoglobulin was started with subsequent improvement.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages9

Reading Time23 min

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Introduction

Case Presentation

Diagnostic Evaluation

MRI Findings

How to Cite

Review began 11/25/2025 Review ended 12/01/2025 Published 12/06/2025 © Copyright 2025 Riyadh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98602 Open Access Case Report Early Sensory-Predominant Guillain-Barré Syndrome With Normal Cerebrospinal Fluid and MRI Findings: A Diagnostic Challenge Salah Riyadh 1, Robert Knopp 1 1. Emergency Department, Pikeville Medical Center, Pikeville, USA Corresponding author: Salah Riyadh, [salah_riadh@yahoo.com](salah_riadh@yahoo.com) Abstract Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that classically presents with progressive, symmetric weakness and areflexia following a preceding infection. However, early or atypical presentations may lack the hallmark diagnostic features, such as elevated cerebrospinal fluid (CSF) protein or abnormal magnetic resonance imaging (MRI) findings, creating a diagnostic challenge. We present the case of a 46-year-old woman who developed progressive distal paresthesias, gait instability, perioral numbness, hoarseness, and later right foot-drop following a viral-like illness. Initial evaluation revealed normal CSF protein levels, an unremarkable MRI of the brain and spine, and preserved strength, leading to diagnostic uncertainty. Despite these findings, the clinical pattern raised suspicion for early sensorypredominant GBS, and intravenous immunoglobulin therapy was initiated with subsequent clinical improvement. This case underscores the importance of maintaining high clinical suspicion for GBS inpatients with compatible symptoms, even in the absence of classical diagnostic findings, to ensure timely intervention and prevent progression. Categories: Neurology, Internal Medicine, Allergy/Immunology Keywords: acute inflammatory demyelinating polyradiculoneuropathy, cerebrospinal fluid, diagnostic challenge, guillain‒barre syndrome, intravenous immunoglobulin, nerve conduction studies, peroneal neuropathy, sensory neuropathy Introduction Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyradiculoneuropathy that typically follows a viral or bacterial infection and is characterized by rapidly progressive, symmetric weakness and areflexia. The annual incidence ranges from one to two cases per 100,000 people and remains a leading cause of acute flaccid paralysis worldwide [1] . GBS encompasses several heterogeneous pathophysiologic subtypes, including acute inflammatory demyelinating polyradiculoneuropathy (AIDP), acute motor axonalneuropathy (AMAN), acute motor and sensory axonal neuropathy (AMSAN), and Miller Fisher syndrome. In North America, AIDP is the most prevalent subtype and is caused by immune-mediated demyelination of peripheral nerves and nerve roots. The classic diagnostic hallmark is albuminocytologic dissociation, elevated cerebrospinal fluid (CSF) protein without pleocytosis, along with demyelinating changes on nerve conduction studies [2] . However, atypical and early presentations can lack these characteristic findings, creating significant diagnostic uncertainty. Sensory-predominant variants, for instance, may present with distal paresthesias, pain, or gait disturbance before weakness develops, sometimes mimicking peripheral mononeuropathies orradiculopathies [3] . In such cases, both CSF and magnetic resonance imaging (MRI) may appear normal early in the disease course, and electrodiagnostic abnormalities may not yet be evident. Early recognition remains essential, as prompt initiation of intravenous immunoglobulin (IVIG) or plasma exchange can reduce neurological progression and long-term disability. We present a case of early sensorypredominant GBS with normal CSF and MRI findings, highlighting the importance of maintaining clinical suspicion

FAQs

Why can Guillain-Barré syndrome be difficult to diagnose early?

Early or atypical presentations may not show classical hallmarks such as elevated CSF protein or abnormal MRI findings, and electrodiagnostic abnormalities may be absent at first.

What symptoms did the reported patient develop?

The patient experienced progressive distal paresthesias, perioral numbness, hoarseness, gait instability, and later right foot-drop following a viral-like illness.

What diagnostic results were initially normal in this case?

Initial evaluation showed normal CSF protein levels, unremarkable brain and spine MRI, preserved strength, and no acute intracranial abnormalities on imaging.

Sep 29, 2026

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