A 31-year-old previously healthy female presented with 4 days of bilateral numbness that started distally in her feet and hands simultaneously then involved her whole four extremities and the front and back of her trunk. She also lost her balance over the same period, first becoming unable to walk then unable to sit without falling to either side. She also reported difficulty reaching for objects. She denied having double vision, slurring of speech, facial numbness or droop, tremors, limb weakness, abdominal distention, sphincteric problems, or dryness of the mouth or eyes. There was no weight loss, and no joint stiffness, swelling or pain. Family history was unremarkable. She had developed a generalized skin rash that started 10 days prior to the onset of her neurological symptoms, which was diagnosed as a primary Chickenpox infection by a dermatologist who prescribed oral acyclovir.
Neurological examination demonstrated normal higher mental functions and intact cranial nerves, with no nystagmus, ptosis, or limitation of eye movements. Muscle strength was 5/5 throughout. Sensory examination was remarkable for severe impairment in joint position and vibration sensation in both upper limbs to the elbows and lower limbs to the knees. Pain and temperature sensation were symmetrically impaired over both upper and lower limbs and the trunk, but the impairment was more pronounced over the anterior trunk than the back. There was no sensory level. Reflexes were absent all over. Babinski's sign was negative bilaterally. Coordination revealed impaired finger to nose and heel to shin, with significant exacerbation by eye closure. She could not maintain a sitting position due to severe truncal ataxia and demonstrated pseudo-athetoid movements in the hands. Dysautonomic signs such as blood pressure and pulse fluctuations were absent, and there was no ileus.
Initial basic labs were normal. Lumbar puncture revealed CSF protein 61.1 mg/dl (reference range 15-45 mg/dl), with normal CSF white cell count (3 cells). CSF cultures and viral PCRs were negative, including HSV I and II, Mycobacterium tuberculosis (M. tb), Epstein-Barr virus (EBV), Cytomegalovirus (CMV), and enterovirus PCRs. CSF VZV PCR was unavailable. Brain MRI with and without contrast was normal. Whole spine MRI with contrast demonstrated enhancement in multiple thoracic and lumbar nerve roots (Figure 1). NCS performed on the fifth day of admission (Table 1) showed absent sensory responses in her four extremities, with normal motor responses and F-waves. Initial electromyography "EMG" using concentric needle was normal (Table 2). Serum VZV IgM was elevated (18.9). HIV screen was negative. Serum B12, folate, thyroid, zinc, vitamin E, and Creatine Kinase "CK" were within normal limits. Serum protein electrophoresis and immunofixation electrophoresis were negative. A paraneoplastic panel, including Hu, Yo, Amphiphysin, Ri, CV2, and Ma2/Ta antibodies, was negative. A comprehensive autoimmune panel was also negative. Ganglioside antibody screen also was negative. CT scan of the chest, abdomen and pelvis did not reveal any malignancy.  
Symptoms peaked two weeks from onset. A diagnosis of sensory GBS was made based on clinical presentation, supportive investigations, and the exclusion of alternative diagnoses. The patient received intravenous immunoglobulin "IVIG" 0.4 gm/kg daily for five days. At discharge, she had a GBS disability score of 4 (bedridden or chair bound). On follow up six weeks later she reported improvement in numbness and unsteadiness. She could stand unsupported with her eyes open but fell if they were closed and could not walk independently. On examination, her dysmetria showed improvement but was still worsened with eye closure. Improvement was noted in all sensory modalities and the pseudo-athetoid movements. Repeat NCS was similar (Table 1). EMG was remarkable for minimal denervation activity in the right anterior tibialis, gastrocnemius, and lower lumbar paraspinal muscles (Table 2). Clinical examination six months after admission demonstrated significant improvement in pinprick and temperature sensation, and proprioception impairment was limited to fingers and toes. She walked independently. Dysmetria was mild but still exacerbated with eye closure. Trace deep tendon reflexes reemerged. She had a GBS disability score of two (able to walk 10 meters or more without assistance but unable to run). Further improvement was evident at her eight-month follow up. EMG studies performed at months six and eight demonstrated persistence of minimal denervation in several upper and lower extremity muscles (Table 2).