Is a second cycle of immunoglobulin justified in axonal forms of Guillain-Barré syndrome?

Objective: In certain situations, severe forms of Guillain-Barré syndrome (GBS) show no response or continue to deteriorate after intravenous immunoglobulin (IVIg) infusion. It is unclear what the best treatment option would be in these circumstances. Method: This is a case report on patients with severe axonal GBS in whom a second cycle of IVIg was used. Results: Three patients on mechanical ventilation who presented axonal variants of GBS, with autonomic dysfunction, bulbar impairment and Erasmus score > 6, showed no improvement after IVIg infusion of 400 mg/kg/d for 5 days. After 6 weeks, we started a second cycle of IVIg using the same doses and regimen as in the previous one. On average, 5 days after the second infusion, all the patients were weaned off mechanical ventilation and showed resolution of their blood pressure and heart rate fluctuations. Conclusions: A second cycle of IVIg may be an option for treating severe forms of GBS.