Prolonged bilateral vocal cord paralysis as an isolated sequela of fulminant Guillain-Barré syndrome after Campylobacter jejuni enteritis

Prolonged bilateral vocal cord paralysis as an isolated sequela of fulminant Guillain-Barré syndrome after Campylobacter jejuni enteritis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Prolonged bilateral vocal cord paralysis as an isolated sequela of fulminant Guillain-Barré syndrome after Campylobacter jejuni enteritis Tomohiro Shogase, Kotaro Tamagawa, Michiaki Koga, Takuya Matsushita This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9106328/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Guillain-Barré syndrome (GBS) rarely presents with bilateral vocal cord paralysis (BVCP), and persistent BVCP as an isolated long-term sequela is exceptionally uncommon. We describe the clinical course of fulminant axonal GBS complicated by prolonged BVCP and discuss its implications for airway management. Case presentation A previously healthy man in his early 50s developed rapidly progressive tetraplegia, multiple cranial neuropathies and respiratory failure several days after an episode of enteritis, ultimately progressing to a near-locked-in state. Anti-GT1a IgG antibodies were strongly positive, and serology was consistent with recent C. jejuni infection. Despite immunotherapy and near-complete recovery of limb strength and bulbar function, serial laryngoscopy demonstrated persistent BVCP with vocal cords fixed in the paramedian position, precluding decannulation and necessitating long-term tracheostomy. Conclusion BVCP may persist as the sole disabling sequela even after marked systemic motor recovery in severe axonal GBS, potentially reflecting the length-dependent vulnerability and protracted reinnervation of the recurrent laryngeal nerve. Upper airway evaluation should be incorporated into ventilator weaning protocols and tracheostomy management, particularly in severe GBS. Guillain-Barré syndrome Vocal cord paralysis Campylobacter jejuni enteritis Airway management Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Guillain-Barré syndrome (GBS) is an acute peripheral neuropathy caused by autoimmune cross-reactivity, often triggered by infectious enteritis due to Campylobacter jejuni or various respiratory tract infections. The disease typically presents with flaccid limb paralysis; however, facial nerve palsy, bulbar palsy, or respiratory failure can occasionally be the initial manifestations. Although the symptoms of GBS typically reach their peak within four weeks after onset and gradually improve thereafter, severe cases may result in long-term disability. Vocal cord paralysis is a rare manifestation of GBS, and persistent vocal cord paralysis as an isolated sequela has been rarely reported. Its pathogenesis remains uncertain and may easily be overlooked, particularly in patients undergoing mechanical ventilation. Here we report a severe case of the axonal GBS in which BVCP persisted for over fifteen months, long after the complete recovery of limb strength and other bulbar functions. Case presentation A previously healthy Japanese man in his early 50s developed watery diarrhea after consuming homemade seasoned chicken breast. Four days after the onset of diarrhea, he noticed mild muscle weakness and abnormal tingling sensations in the tip of his tongue and his extremities. He was referred for neurological evaluation, and on the same day (Day 1), intravenous immunoglobulin (IVIg) therapy (400 mg/kg/day for five consecutive days) was initiated under a strong clinical suspicion of GBS. However, his condition deteriorated almost hourly, and he required endotracheal intubation the following day due to respiratory failure. Tracheostomy was performed on Day 7, but his general condition remained critical, with violent fluctuations in blood pressure and the development of new-onset dissecting aneurysm of the celiac artery (Fig. 1 ). Although he was awake and alert, he rapidly entered an almost completely locked-in state as his paralysis progressed. On Day 11, his Medical Research Council (MRC) sum score for all muscle groups was zero, and all tendon reflexes were absent. His cranial nerve functions were severely impaired, involving the trigeminal (V), abducens (VI), facial (VII), glossopharyngeal (IX), vagus (X), accessory (XI) and hypoglossal (XII) nerves. He could communicate only through limited eye movements and faint head rotations, and required tube feeding because of bulbar palsy. The soft palate showed poor elevation on both sides. The vocal cord findings during intubation were not documented. Vibration sense was slightly reduced, while other sensory modalities were preserved. Laboratory findings revealed no abnormalities in complete blood count and blood chemistry. Other possible etiologies, including vasculitis, sarcoidosis, myasthenia gravis, connective tissue diseases and intracranial infections were excluded. Serum IgG antibodies reacting strongly with GT1a and weakly with GQ1b were detected (Koga J Neurol (2012) 259:1366–1374). Although blood culture and fecal tests were unremarkable, positive serology for recent C. jejuni infection was proven (Koga Neurology (2005) 64:1605–1611). The key clinical data are summarized in Table 1 . The nerve conduction study demonstrated that compound muscle action potential (CMAP) and F waves could be hardly evoked in all limbs tested (Fig. 2 ), findings consistent with severe axonal neuropathy. Table 1 Laboratory findings on admission. Blood sample RBC 5.58×10 6 /µL Alb 4.6 g/dL CRP 0.27 mg/dL Hb 17.2 g/dL ALP 83 U/L BNP 8.5 pg/mL Ht 50.8 % ALT 32 U/L HBs Ag - WBC 7.93×10 3 /µL AST 29 U/L HCV Ab - Neut 56.0 % LDH 225 U/L RPR - Ly 30.0 % CK 65 U/L TPHA - Mono 7.0 % BUN 12.6 mg/dL VCA IgM - Eosino 1.5 % Cr 0.78 mg/dL CMV IgM - Baso 0.0 % Glucose 77 mg/dL ANA < 40 pH 7.404 SS-A/Ro Ab - PaO 2 79.6 mmHg Na 143 mEq/L SS-B/La Ab - PaCO 2 42.4 mmHg K 4.0 mEq/L P-ANCA - HCO 3 − 26.0 mmol/L Cl 104 mEq/L C-ANCA - Lactate 8.0 mmol/L Ca 9.8 mg/dL AChR Ab - Mg 2.6 mg/dL MuSK Ab - P 3.2 mg/dL ACE 5.3 IU/L Anti-glycolipid antibody screening CSF sample IgG IgM Appearance transparent GM2 - - Cell 1 /µL GM1 1+ - Polymorpho- nuclear 0.0 % GD1a 1+ - Mononuclear 100.0 % GD1b 1+ - Protein 60 mg/dL GT1b 1+ - Glucose 52 mg/dL GQ1b 1+ - pH 8.4 GalNAc-GD1a - - GT1a 3+ - Gal-C 1+ 1+ Positive results of anti-glycolipid antibodies are displayed in six levels (from 1 + to 6+); Neut – neutrophil; Ly – lymphocyte; Mono – monocyte; Eosino – eosinophil; Baso – basophil; Ag – antigen; Ab – antibody; Gal — galactocerebroside; AChR — acetylcholine receptor; MuSK — muscle-specific tyrosine kinase His symptoms peaked around Day 14 and gradually improved thereafter; however, the initial recovery was discouragingly slow, as illustrated in Fig. 3 . The dissecting aneurysm of the celiac artery was managed conservatively and followed an uneventful course. Approximately 100 days after onset, a subtle improvement in his facial expressions and a significant return of muscle contraction in the lower extremities were observed. Fortunately, the rate of recovery markedly accelerated about seven months after admission, and the patient regained independent ambulation over the following three months. Recovery of respiratory function was also delayed. He was finally weaned from mechanical ventilation and fitted with a speaking valve approximately six months after tracheostomy. The movement of the soft palate recovered fully. However, he experienced episodes of dyspnea whenever the tracheostomy cannula was displaced or occluded. Laryngoscopic examination revealed bilateral vocal cords fixed in the paramedian position with no detectable abduction during inspiration, accounting for the recurrent dyspnea. Computed tomography (CT) of the trunk and magnetic resonance imaging (MRI) of the brain showed no structural abnormalities along the vagus nerve or its recurrent laryngeal branches. Because the tracheostomy site could not be closed, he has been closely followed after discharge. Fifteen months after onset, BVCP persists as the only residual deficit (Fig. 4 and the additional movie file show this in more detail), whereas all other muscles have regained nearly full strength, except for impaired hand dexterity due to contracture deformities. Electrophysiological studies of the limbs also demonstrated substantial improvement (Fig. 5 ). Discussion GBS is a well-recognized acute immune-mediated motor polyneuropathy that most commonly presents with ascending limb weakness, often following gastrointestinal or respiratory infections, typically with pathogens such as C. jejuni . Cranial nerve involvement and ventilator-dependent severe cases are not uncommon in GBS, and it is reported more frequently in Asia than in Western countries [ 1 ]. This regional difference is thought to reflect the higher prevalence of the axonal type of GBS, and our case aligns with this clinical phenotype. In general, bulbar palsy, bilateral facial palsy and ophthalmoplegia are well-documented cranial manifestations of GBS; however, clinically significant laryngeal involvement leading to vocal cord paralysis is exceedingly rare. BVCP associated with GBS or its variants has been described only in a small number of case reports and series and may easily be overlooked in the context of severe generalized weakness or prolonged mechanical ventilation. Our case demonstrates a fulminant axonal form of GBS with prolonged ventilator dependence and an unusually protracted course of BVCP that persisted despite near-complete recovery of limb and bulbar motor function. Previous reports have indicated that BVCP can occur at various stages of GBS, ranging from an early presenting manifestation to a delayed complication. In one case from South Korea, hoarseness and dysphagia preceded limb weakness, leading initially to otolaryngological rather than neurological evaluation and delayed recognition of the underlying neuropathy [ 2 ]. Neuromuscular disorders are identified in approximately 26% of patients who initially present with idiopathic vocal cord paralysis [ 3 ]. Because these encompass a broad spectrum of diseases, including cerebrovascular disorders, multiple sclerosis and neurodegenerative conditions such as motor neuron disease and multiple system atrophy, the differential diagnosis of acute vocal cord paralysis should always include neuromuscular etiologies. As Kim et al. emphasized, GBS should not be excluded even in the absence of generalized muscle weakness [ 4 ]. In other reported cases, upper airway obstruction due to BVCP developed after the diagnosis of GBS, often during recovery from respiratory failure, frequently necessitating prolonged tracheostomy management [ 5 ][ 6 ]. Our case falls into this latter category: BVCP became clinically evident when ventilator weaning and transition to a speaking valve were attempted. Laryngoscopy revealed bilateral vocal cord immobility, and despite substantial neurological recovery elsewhere, decannulation remained impossible even fifteen months after the onset — highlighting the potential for BVCP to determine long-term airway and functional outcome. The pathophysiological basis of BVCP in GBS remains incompletely understood, but several mechanisms have been proposed. Because vocal cord movement is primarily controlled by the recurrent laryngeal nerve (RLN), bilateral dysfunction likely reflects a predominantly peripheral motor cranial neuropathy involving the vagus nerve and its branches. This hypothesis is supported by reports of concomitant lower cranial nerve involvement [ 7 ][ 8 ][ 9 ] and pathological evidence of axonal or demyelinating lesions affecting motor fibers of bulbar muscles [ 10 ]. In Fisher syndrome (FS) and FS/GBS overlap, where ophthalmoplegia and ataxia predominate, BVCP has also been observed, suggesting that immune-mediated injury may selectively target multiple cranial nerves in a characteristic pattern [ 5 ]. Anti-ganglioside antibodies — particularly anti-GT1a IgG — are closely associated with axonal variants and with pronounced bulbar or lower cranial nerve involvement [ 11 ][ 12 ]. They are thought to play a cardinal role by binding to ganglioside-rich nodal or paranodal regions and triggering complement-mediated injury. The severe axonal pattern on nerve conduction studies and the strongly positive anti-GT1a antibodies in our patient support this immunopathogenic mechanism. Furthermore, the persistent BVCP in our case, despite recovery of other lower cranial nerve functions (including soft palate movements), may relate to the exceptional length of the RLN, particularly on the left. Axonal regeneration across long distances is often incomplete or misdirected, leading to simultaneous activation of antagonistic laryngeal muscles and resulting in functional immobility rather than simple paralysis [ 13 ]. Historically, Wagner and Grossman proposed that length-dependent nerve injury could cause earlier recovery of the superior laryngeal nerve (SLN) compared with RLN, which innervates the cricothyroid muscle responsible for closing the vocal cords. As a result, bilateral vocal cords may remain fixed in the paramedian position. This anatomical vulnerability may explain why severe laryngeal dysfunction requiring permanent tracheostomy can persist as a long-term sequela even after full recovery of systemic weakness, particularly in cases associated with anti-GT1a antibodies. From a clinical standpoint, BVCP in the context of GBS presents several diagnostic and management challenges. First, BVCP may masquerade as a primary laryngeal or structural airway disorder, particularly when limb weakness is mild or absent at initial presentation. This can lead to investigations focused on local causes such as trauma, postsurgical injury, malignancy or idiopathic neuropathy. Several reports have shown that initial imaging and routine laboratory evaluations are often unrevealing, and that only the subsequent development of neurological signs, cerebrospinal fluid changes and electrophysiological abnormalities establishes the diagnosis of GBS [ 2 ][ 4 ][ 5 ]. Second, respiratory failure in GBS is usually attributed to diaphragmatic or intercostal muscle weakness; however, BVCP can independently contribute to upper airway obstruction or hinder decannulation despite adequate respiratory muscle recovery. In our case, the patient was successfully weaned from mechanical ventilation but remained tracheostomy-dependent due to persistent BVCP, exemplifying how laryngeal involvement can represent the principal limiting factor in achieving full respiratory recovery. As summarized in Table 2 , the prognosis of BVCP associated with GBS is variable. Some patients experience relatively rapid resolution of vocal cord immobility, paralleling or shortly following systemic neurological recovery, with successful decannulation and complete resolution of hoarseness or stridor within weeks. Others — including several reported and our own patient — show a markedly protracted course, with BVCP persisting for months to over a year, occasionally necessitating permanent tracheostomy. There is substantial heterogeneity in the reversibility of laryngeal dysfunction. Factors potentially influencing prognosis include the underlying GBS subtype, the extent of axonal damage, the presence of anti-ganglioside antibodies associated with severe cranial neuropathy, and possibly patient age or comorbidities; however, conclusive predictors have not been established. Our case represents the first reported case of BVCP in GBS following C. jejuni enteritis. Table 2 Previous reports of GBS presenting with BVCP and their clinical characteristics. Author /Year Age /Gender Preceding infections/pathogens First symptoms Other cranial nerve involvement Progressive muscle weakness Ventilator use for respiratory failure Recovery of vocal cord mobility Lee DH, et al. (2013) [ 2 ] 61F RTI M. pneumoniae , EBV? Hoarseness, dysphagia - + (3 days after onset) + + (1 month) Son SA, et al. (2022) [ 4 ] 82F COVID-19 vaccination? Dyspnea - - + unknown Bahk J, et al. (2021) [ 5 ] 65M Chickenpox (1 month prior), VZV Diplopia, dizziness III (mild bilateral ptosis) + (6 days after onset) + - Rodrigues JF, et al. (1984) [ 6 ] 64M RTI Lower limb weakness - + (the first symptom) + - Turan MI, et al. (2014) [ 14 ] 11M RTI Tingling and numbness of lower limbs - + (14 days after onset) - + Yoskovitch A, et al. (2000) [ 15 ] 70M RTI Dyspnea, dysphonia - + (3 days after onset) - (only tracheostomy) - Panosian MS, et al. (1993) [ 16 ] 33F - Hoarseness, dysphagia, lower limb weakness III, IV, VI, VII, IX, X, XI, XII + (the first symptom) + + (6 weeks) The reported cases show variation in age and sex, with respiratory tract infections being the most common preceding events. Some patients initially presented with hoarseness or dyspnea, whereas in others BVCP was recognized only after treatment for GBS had begun. All but one patient required tracheostomy due to respiratory failure secondary to respiratory muscle paralysis. Recovery from BVCP appeared more frequent in younger patients, although considerable interindividual variability was observed. None of the available reports specified whether anti-ganglioside antibodies were detected in patient serum. M – male; F – female; RTI – respiratory tract infection The management of BVCP in GBS requires close multidisciplinary collaboration among neurologists, intensivists and otolaryngologists. Intravenous immunoglobulin and plasmapheresis — the standard disease-modifying therapies for GBS — remain the cornerstone of treatment and should be initiated promptly once GBS is suspected, as earlier intervention is associated with faster recovery and a lower likelihood of prolonged mechanical ventilation in severe cases. However, no specific therapy has been proven to facilitate recovery of BVCP itself. Most cases are managed with supportive airway strategies tailored to symptom severity and the risk of obstruction. Tracheostomy should be considered when upper airway compromise or prolonged ventilatory support is anticipated, and the decisions regarding decannulation should take into account both respiratory muscle strength and laryngeal mobility, typically guided by serial laryngoscopic assessments. In patients with persistent BVCP, surgical options such as posterior cordotomy, arytenoidectomy or other glottic-widening procedures may be considered, although these involve balancing airway patency against phonatory quality [ 17 ][ 18 ]. A high body mass index (BMI) and underlying neurological disorders have been associated with a higher risk of surgical treatment failure [ 19 ]; therefore, individualized multidisciplinary discussion of surgical and rehabilitative approaches is warranted. Conclusion This case contributes to the limited but expanding body of literature indicating that BVCP, although rare, represents an important and potentially persistent manifestation of GBS and its variants. Clinicians should maintain high vigilance for GBS in patients presenting with new-onset BVCP, particularly when there is a recent history of infection or subtle neurological deficits accompanying laryngeal symptoms. In patients with established GBS — especially those with severe bulbar involvement or axonal subtypes associated with anti-GT1a antibodies — careful assessment of the upper airway during ventilator weaning is essential to identify unrecognized BVCP that may hinder successful decannulation. While gradual systemic motor recovery is typical of GBS, the exceptional length and complex reinnervation process of the RLN may predispose patients to long-lasting laryngeal dysfunction. Early recognition of this complication and long-term, multidisciplinary follow-up are crucial for optimizing airway management, functional recovery and quality of life in this small but clinically important subgroup of patients. Abbreviations BVCP bilateral vocal cord paralysis C. jejuni Campylobacter jejuni GBS Guillain—Barré syndrome RLN recurrent laryngeal nerve SLN superior laryngeal nerve Declarations Ethics approval and consent to participate: Not applicable Clinical trial number: Not applicable Consent for publication: Written informed consent has been obtained from the patient. Availability of data and materials: Not applicable Competing interests: None Funding: None Authors’ contributions: TS was primarily responsible for drafting the manuscript, while KT and MK provided clinical information including examination findings. MK and TM reviewed and edited the manuscript and provided overall supervision. Acknowledgements: None Author’s information: Not applicable References Doets AY, Verboon C, Berg B, Harbo T, Cornblath DR, Willison HJ, et al. Regional variation of Guillain-Barré syndrome. Brain. 2018;141(10):2866–77. Lee DH, Lee CJ, Lee JW, Lee JK. Guillain-Barré syndrome presenting as bilateral vocal cord paralysis. Korean J Otorhinolaryngol Head Neck Surg. 2013;56(3):169–71. Urquhart AC. St. Louis EK. Idiopathic vocal cord palsies and associated neurological conditions. Arch Otolaryngol Head Neck Surg. 2005;131(12):1086–9. Son SA, Kim YJ, Lim SY, Kim HB. Bilateral vocal fold paralysis after COVID-19 mRNA vaccination: A case report. J Korean Med Sci. 2022;37(25):e201. Bahk J, Yang W, Fishman J. Bilateral vocal cord paralysis in Miller Fisher syndrome/ Guillain-Barré overlap syndrome and a review of previous case series. BMJ Case Rep. 2021;14(1):e240386. Rodrigues JF, York EL, Nair CP. Upper airway obstruction in Guillain-Barré syndrome. Chest. 1984;86(1):147–8. Lyu RK, Chen ST. Acute multiple cranial neuropathy: a variant of Guillain-Barré syndrome? Muscle Nerve. 2004;30(4):433–6. Nanda SK, Jayalakshmi S, Ruikar D, Surath M. Twelfth cranial nerve involvement in Guillain-Barré syndrome. J Neurosci Rural Pract. 2013;4(3):338–40. Tan AK, Chee MW. Fulminant Guillain-Barré syndrome with quadriplegia and total paresis of motor cranial nerves as a result of segmental demyelination. J Neurol Sci. 1995;134(1–2):203–6. Maier H, Schmidbauer M, Pfausler B, Schmutzhard E, Budka H. Central nervous system pathology in patients with the Guillain-Barré syndrome. Brain. 1997;120(3):451–64. Koga M, Yuki N, Hirata K. Antiganglioside antibody in patients with Guillain-Barré syndrome who show bulbar palsy as an initial symptom. J Neurol Neurosurg Psychiatry. 1999;66(4):513–6. Kim JK, Kim BJ, Shin HY, Shin KJ, Nam TS, Oh JY, et al. Acute bulbar palsy as a variant of Guillain-Barré syndrome. Neurology. 2016;86(8):742–7. Sercarz JA, Nguyen L, Nasri S, Graves MC, Wenokur R, Berke GS. Physiologic motion after laryngeal nerve reinnervation: a new method. Otolaryngol Head Neck Surg. 1997;116(4):466–74. Turan MI, Özden Ö, Disci E, Tan H. Atypical presentation of Guillain-Barré syndrome. Eur J Gen Med. 2014;11(2):119–20. 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Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.avi Additional files File name: Additional file 1 File format: .avi Title of data: Laryngoscopic findings of the patient’s vocal cords Description of data: The bilateral vocal cords are fixed in the paramedian position, without any abduction during inspiration. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9106328","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":610755806,"identity":"6cc62592-edcd-4c6f-ac41-47c44df6bb65","order_by":0,"name":"Tomohiro Shogase","email":"data:image/png;base64,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","orcid":"","institution":"Kochi Medical School Hospital","correspondingAuthor":true,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Shogase","suffix":""},{"id":610755807,"identity":"5f29ae40-83a2-492c-97d8-60ff45ae0e34","order_by":1,"name":"Kotaro Tamagawa","email":"","orcid":"","institution":"Kochi Medical School Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kotaro","middleName":"","lastName":"Tamagawa","suffix":""},{"id":610755808,"identity":"9c6f8856-6f5e-4e51-bef7-2bea017510a1","order_by":2,"name":"Michiaki Koga","email":"","orcid":"","institution":"Yamaguchi University Graduate School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Michiaki","middleName":"","lastName":"Koga","suffix":""},{"id":610755809,"identity":"aa7315bb-a5d7-4747-b056-78ad2cbab4b3","order_by":3,"name":"Takuya Matsushita","email":"","orcid":"","institution":"Kochi Medical School Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takuya","middleName":"","lastName":"Matsushita","suffix":""}],"badges":[],"createdAt":"2026-03-12 15:09:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9106328/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9106328/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105409905,"identity":"0409d86b-667a-4966-9920-1f675eb0dfc3","added_by":"auto","created_at":"2026-03-25 17:11:15","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":218358,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological findings of the celiac artery aneurysm. (A) Contrast-enhanced CT shows narrowing at the origin of the celiac artery, followed by a 13 mm saccular dilatation (arrow). At this stage, the differential diagnosis included a dissecting aneurysm or an infectious aneurysm. (B), (C) Magnetic resonance angiography (MRA) demonstrates an extensive dissection extending from the celiac artery (arrow) to the common hepatic and splenic arteries. The findings are consistent with a thrombosed false-lumen type dissection. The aneurysm was managed conservatively and remained stable.\u003c/p\u003e","description":"","filename":"Figure1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9106328/v1/73561bcead258c2dd1c0acbc.jpeg"},{"id":105565707,"identity":"2ca9ec4d-6f27-4c0f-beb4-d82ad7db6f2d","added_by":"auto","created_at":"2026-03-27 12:54:07","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":318584,"visible":true,"origin":"","legend":"\u003cp\u003eElectrophysiological findings on Day 11. Representative waveforms from motor and sensory nerve conduction studies. (A), (B) Motor nerve conduction studies of the right median and peroneal nerves demonstrate a generalized, profound reduction in compound muscle action potential (CMAP) amplitudes; responses were nearly unelicitable in all limbs tested. F waves were completely absent. (C), (D) Sensory nerve conduction studies show a marked reduction in sensory nerve action potential (SNAP) amplitudes, with only minimal preservation in the right sural nerve. No definitive demyelinating features, such as prolonged distal latencies or marked slowing of conduction velocities, were observed.\u003c/p\u003e","description":"","filename":"Figure2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9106328/v1/d11c81ea65930d01bafb766c.jpeg"},{"id":105409906,"identity":"c0c624e8-7f81-488c-a0a4-374c278fa0a1","added_by":"auto","created_at":"2026-03-25 17:11:15","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":183342,"visible":true,"origin":"","legend":"\u003cp\u003eClinical course and recovery of motor function. The graph illustrates the patient’s neurological progression, as measured by the Medical Research Council (MRC) sum score (maximum = 60 across 12 muscle groups). IVIg therapy was initiated immediately after admission, but the patient required intubation shortly thereafter, and tracheostomy was performed on Day 7. By that time, multiple cranial nerve symptoms had developed, including ophthalmoplegia and facial weakness; however, assessment of vocal cord mobility was not possible because mechanical ventilation was required for respiratory muscle paralysis. Over time, limb strength and cranial nerve deficits gradually improved, enabling transition to a speaking valve approximately six months after tracheostomy. Bilateral vocal cord paralysis was subsequently identified during daily rehabilitation and recurrent episodes of dyspnea. The patient ultimately regained independent ambulation, but tracheal decannulation proved difficult.\u003c/p\u003e","description":"","filename":"Figure3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9106328/v1/95de737ed2f9628fa23a13b3.jpeg"},{"id":105409902,"identity":"e1c3d6d7-9ce7-490b-8b00-5eb95237fc35","added_by":"auto","created_at":"2026-03-25 17:11:15","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":206356,"visible":true,"origin":"","legend":"\u003cp\u003eLaryngoscopic findings eleven months after disease onset. Still images from flexible fiberoptic laryngoscopy during (A) inspiration and (B) expiration. The bilateral vocal cords are fixed in the paramedian position (arrows). No abduction of either vocal cord is observed during deep inspiration.\u003c/p\u003e","description":"","filename":"Figure4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9106328/v1/6b74aa5be787eb234d3a8fa1.jpeg"},{"id":105409904,"identity":"dc0eb29e-dfd1-4f61-8115-1c60311456ad","added_by":"auto","created_at":"2026-03-25 17:11:15","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":376630,"visible":true,"origin":"","legend":"\u003cp\u003eElectrophysiological findings one year after disease onset. Marked improvement is observed in CMAP and SNAP amplitudes in most nerves examined.\u003c/p\u003e","description":"","filename":"Figure5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9106328/v1/728ea8299b97547090074f9c.jpeg"},{"id":106202142,"identity":"08b40aae-12b4-4c36-9478-d3e5d5450f3c","added_by":"auto","created_at":"2026-04-06 03:39:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1968559,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9106328/v1/2c93e1da-01cb-48cb-950e-c891ea17ede1.pdf"},{"id":105409909,"identity":"21335cbe-735c-4323-9c40-3e6922fc87e0","added_by":"auto","created_at":"2026-03-25 17:11:18","extension":"avi","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":106363024,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional files\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFile name: Additional file 1\u003c/p\u003e\n\u003cp\u003eFile format: .avi\u003c/p\u003e\n\u003cp\u003eTitle of data: Laryngoscopic findings of the patient’s vocal cords\u003c/p\u003e\n\u003cp\u003eDescription of data: The bilateral vocal cords are fixed in the paramedian position, without any abduction during inspiration.\u003c/p\u003e","description":"","filename":"Additionalfile1.avi","url":"https://assets-eu.researchsquare.com/files/rs-9106328/v1/00d61b26a996b36558e72bf8.avi"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prolonged bilateral vocal cord paralysis as an isolated sequela of fulminant Guillain-Barré syndrome after Campylobacter jejuni enteritis","fulltext":[{"header":"Background","content":"\u003cp\u003eGuillain-Barr\u0026eacute; syndrome (GBS) is an acute peripheral neuropathy caused by autoimmune cross-reactivity, often triggered by infectious enteritis due to \u003cem\u003eCampylobacter jejuni\u003c/em\u003e or various respiratory tract infections. The disease typically presents with flaccid limb paralysis; however, facial nerve palsy, bulbar palsy, or respiratory failure can occasionally be the initial manifestations. Although the symptoms of GBS typically reach their peak within four weeks after onset and gradually improve thereafter, severe cases may result in long-term disability. Vocal cord paralysis is a rare manifestation of GBS, and persistent vocal cord paralysis as an isolated sequela has been rarely reported. Its pathogenesis remains uncertain and may easily be overlooked, particularly in patients undergoing mechanical ventilation. Here we report a severe case of the axonal GBS in which BVCP persisted for over fifteen months, long after the complete recovery of limb strength and other bulbar functions.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA previously healthy Japanese man in his early 50s developed watery diarrhea after consuming homemade seasoned chicken breast. Four days after the onset of diarrhea, he noticed mild muscle weakness and abnormal tingling sensations in the tip of his tongue and his extremities. He was referred for neurological evaluation, and on the same day (Day 1), intravenous immunoglobulin (IVIg) therapy (400 mg/kg/day for five consecutive days) was initiated under a strong clinical suspicion of GBS. However, his condition deteriorated almost hourly, and he required endotracheal intubation the following day due to respiratory failure. Tracheostomy was performed on Day 7, but his general condition remained critical, with violent fluctuations in blood pressure and the development of new-onset dissecting aneurysm of the celiac artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Although he was awake and alert, he rapidly entered an almost completely locked-in state as his paralysis progressed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOn Day 11, his Medical Research Council (MRC) sum score for all muscle groups was zero, and all tendon reflexes were absent. His cranial nerve functions were severely impaired, involving the trigeminal (V), abducens (VI), facial (VII), glossopharyngeal (IX), vagus (X), accessory (XI) and hypoglossal (XII) nerves. He could communicate only through limited eye movements and faint head rotations, and required tube feeding because of bulbar palsy. The soft palate showed poor elevation on both sides. The vocal cord findings during intubation were not documented. Vibration sense was slightly reduced, while other sensory modalities were preserved. Laboratory findings revealed no abnormalities in complete blood count and blood chemistry. Other possible etiologies, including vasculitis, sarcoidosis, myasthenia gravis, connective tissue diseases and intracranial infections were excluded. Serum IgG antibodies reacting strongly with GT1a and weakly with GQ1b were detected (Koga J Neurol (2012) 259:1366\u0026ndash;1374). Although blood culture and fecal tests were unremarkable, positive serology for recent \u003cem\u003eC. jejuni\u003c/em\u003e infection was proven (Koga Neurology (2005) 64:1605\u0026ndash;1611). The key clinical data are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The nerve conduction study demonstrated that compound muscle action potential (CMAP) and F waves could be hardly evoked in all limbs tested (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), findings consistent with severe axonal neuropathy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory findings on admission.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eBlood sample\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRBC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e5.58\u0026times;10\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e/\u0026micro;L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCRP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHb\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eALP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eU/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBNP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" 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colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e30.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eU/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTPHA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMono\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBUN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eVCA IgM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEosino\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCMV IgM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaso\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eANA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e7.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSS-A/Ro Ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e79.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emEq/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSS-B/La Ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e42.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emmHg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emEq/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP-ANCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHCO\u003csub\u003e3\u003c/sub\u003e\u003csup\u003e\u0026minus;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e26.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emEq/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eC-ANCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emmol/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAChR Ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMuSK Ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eACE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIU/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnti-glycolipid antibody screening\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003eCSF sample\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIgG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIgM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAppearance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003etransparent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eCell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e/\u0026micro;L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePolymorpho-\u003c/p\u003e \u003cp\u003enuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGD1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMononuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGD1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eProtein\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGT1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGlucose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003emg/dL\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGQ1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003epH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGalNAc-GD1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGT1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGal-C\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePositive results of anti-glycolipid antibodies are displayed in six levels (from 1\u0026thinsp;+\u0026thinsp;to 6+); Neut \u0026ndash; neutrophil; Ly \u0026ndash; lymphocyte; Mono \u0026ndash; monocyte; Eosino \u0026ndash; eosinophil; Baso \u0026ndash; basophil; Ag \u0026ndash; antigen; Ab \u0026ndash; antibody; Gal \u0026mdash; galactocerebroside; AChR \u0026mdash; acetylcholine receptor; MuSK \u0026mdash; muscle-specific tyrosine kinase\u003c/p\u003e \u003cp\u003eHis symptoms peaked around Day 14 and gradually improved thereafter; however, the initial recovery was discouragingly slow, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The dissecting aneurysm of the celiac artery was managed conservatively and followed an uneventful course. Approximately 100 days after onset, a subtle improvement in his facial expressions and a significant return of muscle contraction in the lower extremities were observed. Fortunately, the rate of recovery markedly accelerated about seven months after admission, and the patient regained independent ambulation over the following three months.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eRecovery of respiratory function was also delayed. He was finally weaned from mechanical ventilation and fitted with a speaking valve approximately six months after tracheostomy. The movement of the soft palate recovered fully. However, he experienced episodes of dyspnea whenever the tracheostomy cannula was displaced or occluded. Laryngoscopic examination revealed bilateral vocal cords fixed in the paramedian position with no detectable abduction during inspiration, accounting for the recurrent dyspnea. Computed tomography (CT) of the trunk and magnetic resonance imaging (MRI) of the brain showed no structural abnormalities along the vagus nerve or its recurrent laryngeal branches. Because the tracheostomy site could not be closed, he has been closely followed after discharge. Fifteen months after onset, BVCP persists as the only residual deficit (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and the additional movie file show this in more detail), whereas all other muscles have regained nearly full strength, except for impaired hand dexterity due to contracture deformities. Electrophysiological studies of the limbs also demonstrated substantial improvement (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGBS is a well-recognized acute immune-mediated motor polyneuropathy that most commonly presents with ascending limb weakness, often following gastrointestinal or respiratory infections, typically with pathogens such as \u003cem\u003eC. jejuni\u003c/em\u003e. Cranial nerve involvement and ventilator-dependent severe cases are not uncommon in GBS, and it is reported more frequently in Asia than in Western countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This regional difference is thought to reflect the higher prevalence of the axonal type of GBS, and our case aligns with this clinical phenotype. In general, bulbar palsy, bilateral facial palsy and ophthalmoplegia are well-documented cranial manifestations of GBS; however, clinically significant laryngeal involvement leading to vocal cord paralysis is exceedingly rare. BVCP associated with GBS or its variants has been described only in a small number of case reports and series and may easily be overlooked in the context of severe generalized weakness or prolonged mechanical ventilation. Our case demonstrates a fulminant axonal form of GBS with prolonged ventilator dependence and an unusually protracted course of BVCP that persisted despite near-complete recovery of limb and bulbar motor function.\u003c/p\u003e \u003cp\u003ePrevious reports have indicated that BVCP can occur at various stages of GBS, ranging from an early presenting manifestation to a delayed complication. In one case from South Korea, hoarseness and dysphagia preceded limb weakness, leading initially to otolaryngological rather than neurological evaluation and delayed recognition of the underlying neuropathy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Neuromuscular disorders are identified in approximately 26% of patients who initially present with idiopathic vocal cord paralysis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Because these encompass a broad spectrum of diseases, including cerebrovascular disorders, multiple sclerosis and neurodegenerative conditions such as motor neuron disease and multiple system atrophy, the differential diagnosis of acute vocal cord paralysis should always include neuromuscular etiologies. As Kim et al. emphasized, GBS should not be excluded even in the absence of generalized muscle weakness [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In other reported cases, upper airway obstruction due to BVCP developed after the diagnosis of GBS, often during recovery from respiratory failure, frequently necessitating prolonged tracheostomy management [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Our case falls into this latter category: BVCP became clinically evident when ventilator weaning and transition to a speaking valve were attempted. Laryngoscopy revealed bilateral vocal cord immobility, and despite substantial neurological recovery elsewhere, decannulation remained impossible even fifteen months after the onset \u0026mdash; highlighting the potential for BVCP to determine long-term airway and functional outcome.\u003c/p\u003e \u003cp\u003eThe pathophysiological basis of BVCP in GBS remains incompletely understood, but several mechanisms have been proposed. Because vocal cord movement is primarily controlled by the recurrent laryngeal nerve (RLN), bilateral dysfunction likely reflects a predominantly peripheral motor cranial neuropathy involving the vagus nerve and its branches. This hypothesis is supported by reports of concomitant lower cranial nerve involvement [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and pathological evidence of axonal or demyelinating lesions affecting motor fibers of bulbar muscles [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Fisher syndrome (FS) and FS/GBS overlap, where ophthalmoplegia and ataxia predominate, BVCP has also been observed, suggesting that immune-mediated injury may selectively target multiple cranial nerves in a characteristic pattern [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Anti-ganglioside antibodies \u0026mdash; particularly anti-GT1a IgG \u0026mdash; are closely associated with axonal variants and with pronounced bulbar or lower cranial nerve involvement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. They are thought to play a cardinal role by binding to ganglioside-rich nodal or paranodal regions and triggering complement-mediated injury. The severe axonal pattern on nerve conduction studies and the strongly positive anti-GT1a antibodies in our patient support this immunopathogenic mechanism.\u003c/p\u003e \u003cp\u003eFurthermore, the persistent BVCP in our case, despite recovery of other lower cranial nerve functions (including soft palate movements), may relate to the exceptional length of the RLN, particularly on the left. Axonal regeneration across long distances is often incomplete or misdirected, leading to simultaneous activation of antagonistic laryngeal muscles and resulting in functional immobility rather than simple paralysis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Historically, Wagner and Grossman proposed that length-dependent nerve injury could cause earlier recovery of the superior laryngeal nerve (SLN) compared with RLN, which innervates the cricothyroid muscle responsible for closing the vocal cords. As a result, bilateral vocal cords may remain fixed in the paramedian position. This anatomical vulnerability may explain why severe laryngeal dysfunction requiring permanent tracheostomy can persist as a long-term sequela even after full recovery of systemic weakness, particularly in cases associated with anti-GT1a antibodies.\u003c/p\u003e \u003cp\u003eFrom a clinical standpoint, BVCP in the context of GBS presents several diagnostic and management challenges. First, BVCP may masquerade as a primary laryngeal or structural airway disorder, particularly when limb weakness is mild or absent at initial presentation. This can lead to investigations focused on local causes such as trauma, postsurgical injury, malignancy or idiopathic neuropathy. Several reports have shown that initial imaging and routine laboratory evaluations are often unrevealing, and that only the subsequent development of neurological signs, cerebrospinal fluid changes and electrophysiological abnormalities establishes the diagnosis of GBS [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Second, respiratory failure in GBS is usually attributed to diaphragmatic or intercostal muscle weakness; however, BVCP can independently contribute to upper airway obstruction or hinder decannulation despite adequate respiratory muscle recovery. In our case, the patient was successfully weaned from mechanical ventilation but remained tracheostomy-dependent due to persistent BVCP, exemplifying how laryngeal involvement can represent the principal limiting factor in achieving full respiratory recovery.\u003c/p\u003e \u003cp\u003eAs summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the prognosis of BVCP associated with GBS is variable. Some patients experience relatively rapid resolution of vocal cord immobility, paralleling or shortly following systemic neurological recovery, with successful decannulation and complete resolution of hoarseness or stridor within weeks. Others \u0026mdash; including several reported and our own patient \u0026mdash; show a markedly protracted course, with BVCP persisting for months to over a year, occasionally necessitating permanent tracheostomy. There is substantial heterogeneity in the reversibility of laryngeal dysfunction. Factors potentially influencing prognosis include the underlying GBS subtype, the extent of axonal damage, the presence of anti-ganglioside antibodies associated with severe cranial neuropathy, and possibly patient age or comorbidities; however, conclusive predictors have not been established. Our case represents the first reported case of BVCP in GBS following \u003cem\u003eC. jejuni\u003c/em\u003e enteritis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevious reports of GBS presenting with BVCP and their clinical characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor\u003c/p\u003e \u003cp\u003e/Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003e/Gender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePreceding infections/pathogens\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFirst symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOther cranial nerve involvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eProgressive muscle weakness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVentilator use for respiratory failure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRecovery of vocal cord mobility\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLee DH, et al. (2013)\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRTI\u003c/p\u003e \u003cp\u003e\u003cem\u003eM. pneumoniae\u003c/em\u003e, EBV?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHoarseness, dysphagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(3 days after onset)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(1 month)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSon SA, et al. (2022)\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCOVID-19 vaccination?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDyspnea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eunknown\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBahk J, et al. (2021)\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChickenpox\u003c/p\u003e \u003cp\u003e(1 month prior), VZV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiplopia, dizziness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIII (mild bilateral ptosis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(6 days after onset)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRodrigues JF, et al. (1984)\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLower limb weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(the first symptom)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTuran MI, et al. (2014)\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTingling and numbness of lower limbs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(14 days after onset)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYoskovitch A, et al. (2000)\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70M\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDyspnea, dysphonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(3 days after onset)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e(only tracheostomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePanosian MS, et al. (1993)\u003c/p\u003e \u003cp\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33F\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHoarseness, dysphagia, lower limb weakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIII, IV, VI, VII, IX, X, XI, XII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(the first symptom)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e+\u003c/p\u003e \u003cp\u003e(6 weeks)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe reported cases show variation in age and sex, with respiratory tract infections being the most common preceding events. Some patients initially presented with hoarseness or dyspnea, whereas in others BVCP was recognized only after treatment for GBS had begun. All but one patient required tracheostomy due to respiratory failure secondary to respiratory muscle paralysis. Recovery from BVCP appeared more frequent in younger patients, although considerable interindividual variability was observed. None of the available reports specified whether anti-ganglioside antibodies were detected in patient serum. M \u0026ndash; male; F \u0026ndash; female; RTI \u0026ndash; respiratory tract infection\u003c/p\u003e \u003cp\u003eThe management of BVCP in GBS requires close multidisciplinary collaboration among neurologists, intensivists and otolaryngologists. Intravenous immunoglobulin and plasmapheresis \u0026mdash; the standard disease-modifying therapies for GBS \u0026mdash; remain the cornerstone of treatment and should be initiated promptly once GBS is suspected, as earlier intervention is associated with faster recovery and a lower likelihood of prolonged mechanical ventilation in severe cases. However, no specific therapy has been proven to facilitate recovery of BVCP itself. Most cases are managed with supportive airway strategies tailored to symptom severity and the risk of obstruction. Tracheostomy should be considered when upper airway compromise or prolonged ventilatory support is anticipated, and the decisions regarding decannulation should take into account both respiratory muscle strength and laryngeal mobility, typically guided by serial laryngoscopic assessments. In patients with persistent BVCP, surgical options such as posterior cordotomy, arytenoidectomy or other glottic-widening procedures may be considered, although these involve balancing airway patency against phonatory quality [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A high body mass index (BMI) and underlying neurological disorders have been associated with a higher risk of surgical treatment failure [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]; therefore, individualized multidisciplinary discussion of surgical and rehabilitative approaches is warranted.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case contributes to the limited but expanding body of literature indicating that BVCP, although rare, represents an important and potentially persistent manifestation of GBS and its variants. Clinicians should maintain high vigilance for GBS in patients presenting with new-onset BVCP, particularly when there is a recent history of infection or subtle neurological deficits accompanying laryngeal symptoms. In patients with established GBS \u0026mdash; especially those with severe bulbar involvement or axonal subtypes associated with anti-GT1a antibodies \u0026mdash; careful assessment of the upper airway during ventilator weaning is essential to identify unrecognized BVCP that may hinder successful decannulation. While gradual systemic motor recovery is typical of GBS, the exceptional length and complex reinnervation process of the RLN may predispose patients to long-lasting laryngeal dysfunction. Early recognition of this complication and long-term, multidisciplinary follow-up are crucial for optimizing airway management, functional recovery and quality of life in this small but clinically important subgroup of patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBVCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebilateral vocal cord paralysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cem\u003eC. jejuni\u003c/em\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eCampylobacter jejuni\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGBS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGuillain\u0026mdash;Barr\u0026eacute; syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRLN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003erecurrent laryngeal nerve\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSLN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esuperior laryngeal nerve\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n\u003cli\u003eEthics approval and consent to participate: Not applicable\u003c/li\u003e\n\u003cli\u003eClinical trial number: Not applicable\u003c/li\u003e\n\u003cli\u003eConsent for publication: Written informed consent has been obtained from the patient.\u003c/li\u003e\n\u003cli\u003eAvailability of data and materials: Not applicable\u003c/li\u003e\n\u003cli\u003eCompeting interests: None\u003c/li\u003e\n\u003cli\u003eFunding: None\u003c/li\u003e\n\u003cli\u003eAuthors\u0026rsquo; contributions: TS was primarily responsible for drafting the manuscript, while KT and MK provided clinical information including examination findings. MK and TM reviewed and edited the manuscript and provided overall supervision.\u003c/li\u003e\n\u003cli\u003eAcknowledgements: None\u003c/li\u003e\n\u003cli\u003eAuthor\u0026rsquo;s information: Not applicable\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDoets AY, Verboon C, Berg B, Harbo T, Cornblath DR, Willison HJ, et al. Regional variation of Guillain-Barr\u0026eacute; syndrome. Brain. 2018;141(10):2866\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee DH, Lee CJ, Lee JW, Lee JK. Guillain-Barr\u0026eacute; syndrome presenting as bilateral vocal cord paralysis. Korean J Otorhinolaryngol Head Neck Surg. 2013;56(3):169\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUrquhart AC. St. Louis EK. Idiopathic vocal cord palsies and associated neurological conditions. Arch Otolaryngol Head Neck Surg. 2005;131(12):1086\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSon SA, Kim YJ, Lim SY, Kim HB. Bilateral vocal fold paralysis after COVID-19 mRNA vaccination: A case report. J Korean Med Sci. 2022;37(25):e201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahk J, Yang W, Fishman J. Bilateral vocal cord paralysis in Miller Fisher syndrome/ Guillain-Barr\u0026eacute; overlap syndrome and a review of previous case series. BMJ Case Rep. 2021;14(1):e240386.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRodrigues JF, York EL, Nair CP. Upper airway obstruction in Guillain-Barr\u0026eacute; syndrome. Chest. 1984;86(1):147\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLyu RK, Chen ST. Acute multiple cranial neuropathy: a variant of Guillain-Barr\u0026eacute; syndrome? Muscle Nerve. 2004;30(4):433\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNanda SK, Jayalakshmi S, Ruikar D, Surath M. Twelfth cranial nerve involvement in Guillain-Barr\u0026eacute; syndrome. J Neurosci Rural Pract. 2013;4(3):338\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTan AK, Chee MW. Fulminant Guillain-Barr\u0026eacute; syndrome with quadriplegia and total paresis of motor cranial nerves as a result of segmental demyelination. J Neurol Sci. 1995;134(1\u0026ndash;2):203\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaier H, Schmidbauer M, Pfausler B, Schmutzhard E, Budka H. Central nervous system pathology in patients with the Guillain-Barr\u0026eacute; syndrome. Brain. 1997;120(3):451\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoga M, Yuki N, Hirata K. Antiganglioside antibody in patients with Guillain-Barr\u0026eacute; syndrome who show bulbar palsy as an initial symptom. J Neurol Neurosurg Psychiatry. 1999;66(4):513\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JK, Kim BJ, Shin HY, Shin KJ, Nam TS, Oh JY, et al. Acute bulbar palsy as a variant of Guillain-Barr\u0026eacute; syndrome. Neurology. 2016;86(8):742\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSercarz JA, Nguyen L, Nasri S, Graves MC, Wenokur R, Berke GS. Physiologic motion after laryngeal nerve reinnervation: a new method. Otolaryngol Head Neck Surg. 1997;116(4):466\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTuran MI, \u0026Ouml;zden \u0026Ouml;, Disci E, Tan H. Atypical presentation of Guillain-Barr\u0026eacute; syndrome. Eur J Gen Med. 2014;11(2):119\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoskovitch A, Enepekides DJ, Hier MP, Black MJ. Guillain-Barr\u0026eacute; syndrome presenting as bilateral vocal cord paralysis. Otolaryngol Head Neck Surg. 2000;122(2):269\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanosian MS, Quatela VC. Guillain-Barr\u0026eacute; syndrome presenting as acute bilateral vocal cord paralysis. Otolaryngol Head Neck Surg. 1993;108(2):171\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Garrett G, Zealear D. Current treatment options for bilateral vocal fold paralysis: A state-of-the-art review. Clin Exp Otorhinolaryngol. 2017;10(3):203\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNawka T, Gugatschka M, K\u0026ouml;lmel JC, M\u0026uuml;ller AH, Stickler BS, Yaremchuk S, et al. Therapy of bilateral vocal fold paralysis: Real world data of an international multi-center registry. PLoS ONE. 2019;14(4):e0216096.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWrzoł MG, Mark\u0026oacute;w M, Janecki D, Orecka B, Warmuziński K, Misiołek M. Analysis of the effectiveness of arytenoidectomy and posterior cordectomy with the use of CFD airflow measurements in patients with BVFP: A restrospective study. Appl Bionics Biomech. 2022 Nov;15:9749034.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Guillain-Barré syndrome, Vocal cord paralysis, Campylobacter jejuni enteritis,\tAirway management","lastPublishedDoi":"10.21203/rs.3.rs-9106328/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9106328/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGuillain-Barré syndrome (GBS) rarely presents with bilateral vocal cord paralysis (BVCP), and persistent BVCP as an isolated long-term sequela is exceptionally uncommon. We describe the clinical course of fulminant axonal GBS complicated by prolonged BVCP and discuss its implications for airway management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;A previously healthy man in his early 50s developed rapidly progressive tetraplegia, multiple cranial neuropathies and respiratory failure several days after an episode of enteritis, ultimately progressing to a near-locked-in state. Anti-GT1a IgG antibodies were strongly positive, and serology was consistent with recent \u003cem\u003eC. jejuni\u003c/em\u003e infection. Despite immunotherapy and near-complete recovery of limb strength and bulbar function, serial laryngoscopy demonstrated persistent BVCP with vocal cords fixed in the paramedian position, precluding decannulation and necessitating long-term tracheostomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBVCP may persist as the sole disabling sequela even after marked systemic motor recovery in severe axonal GBS, potentially reflecting the length-dependent vulnerability and protracted reinnervation of the recurrent laryngeal nerve. Upper airway evaluation should be incorporated into ventilator weaning protocols and tracheostomy management, particularly in severe GBS.\u003c/p\u003e","manuscriptTitle":"Prolonged bilateral vocal cord paralysis as an isolated sequela of fulminant Guillain-Barré syndrome after Campylobacter jejuni enteritis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 17:10:59","doi":"10.21203/rs.3.rs-9106328/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"072c2ee2-2100-43eb-a1c3-bc477f0f0058","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T03:39:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 17:10:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9106328","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9106328","identity":"rs-9106328","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}