Guillain-Barré Syndrome (GBS) is a rare and potentially life-threatening autoimmune disorder characterized by acute onset of muscle weakness, areflexia, and ascending paralysis [1,2]. With an estimated global incidence of 1-2 cases per 100,000 population per year [3], GBS poses a significant diagnostic and therapeutic challenge to healthcare providers worldwide. In India, where the disease burden is substantial, the availability of comprehensive data on GBS is limited, hindering the development of effective management strategies [4]. Despite advances in understanding the pathophysiology of GBS, there remains a significant knowledge gap in the Indian context regarding the epidemiological profile, clinical presentation, and treatment outcomes of patients with GBS [5]. A better understanding of the bio profile, clinical presentation, and treatment outcomes of GBS in the Indian setting is essential to inform the development of evidence-based guidelines and improve patient care [6]. Review of Literature - This retrospective study aims to address this knowledge gap by analysing the bio profile, clinical presentation, and outcomes of patients with GBS at a rural tertiary care, teaching centre in India. • Several studies have examined the clinical features and outcomes of GBS in different populations. For example, a study by Rafiei Tabatabaei S et al. (2021) [7] reported on the occurrence of GBS in a child infected with COVID-19, highlighting the disease’s variability in presentation and severity. Additionally, Terencio BBP et al. (2021) [8] discussed the incidence of GBS in paediatrics patients with COVID-19, emphasizing the importance of early diagnosis and intervention. • In adults, a study by Goel N, Mehndiratta S, Singh A (2021) [9] focused on the bio profile And outcomes of post-COVID-19 GBS in immunocompromised children, providing insights into the disease's impact on vulnerable populations. Another significant contribution is the case report by Kanou S et al. (2022) [10], which described a child with GBS associated with COVID-19 who recovered without treatment, demonstrating the variable prognosis. • Dimachkie MM and Barohn RJ (2016) [11] provided a comprehensive review of GBS variants, while van den Berg B et al. (2018) [12] offered insights into the pathogenesis, diagnosis, treatment, and prognosis of GBS. These studies highlight the complexity of GBS and the need for further research. • Given the limited data, this study aims to contribute to the understanding of GBS in the Indian context, particularly in a tertiary care setting, by analysing patient bio profiles, clinical presentations, complications, ventilation requirements, mortality, and treatment outcomes.

2.1 Source of data GBS patients admitted to Shree Krishna hospital, Karamsad from 2019-2024. 2.2 Methodology • Study Design: Retrospective cohort study. • Study Population: GBS patients admitted to Shree Krishna hospital, Karamsad from 2019-2024 • Data Collection: Electronic medical records will be reviewed and analysed, including demographic data, clinical data, laboratory results, and imaging studies. (Note: As per the ethical consideration provided, patients identity / name will not be used and deidentified data will be used for analysis). 2.3 Plan of statistical analysis Data Analysis: Descriptive statistics will be used to summarize the data, and inferential statistics will be used to compare the findings to previous studies. (Note: For this specific dataset, only descriptive statistics were performed due to limitations in data detail).

This retrospective study analysed data from 137 patients diagnosed with Guillain-Barré Syndrome (GBS) admitted to Shree Krishna hospital, Karamsad between 2019 and 2024. Demographics: Table 1 presents the demographic characteristics of the cohort. The majority of patients (65.7%) were older than 18 years. Males constituted a larger proportion (59.9%) compared to females (40.1%). Table 1: Demographic Characteristics Characteristic Category Count (n) Percentage (%) Age Less than 18yr 47 34.3% More than 18 yr 90 65.7% Gender Male (M) 82 59.9% Female (F) 55 40.1% Total Patients 137 100.0% Table 2, the majority of patients (70.8%) had no reported comorbidities. Among those with comorbidities, hypertension (10.9%), diabetes mellitus (9.5%), and thyroid disorder (6.6%) were the most prevalent. A preceding viral infection was documented in 22.6% of cases, including 7 patients with a history of Post COVID infection. Table 2: Comorbidities and Preceding Events Characteristic Category Count (n)* Percentage (%)* Comorbidities NO COMORBIDITIES 97 70.8% (Patients with ≥1 comorbidity) (Excluding "NO COMORBIDITIES") 40 2S.2% Specific Comorbidities (among patients with comorbidities) DM 13 9.5% HTN 15 10.9% THYROID DISORDER 9 6.6% POST COVID 7 5.1% TB 2 1.5% CKD 2 1.5% ALCOHOL INTOXICATION 1 0.7% BLEEDING TENDENCY 1 0.7% CANCER 1 0.7% Post viral INFECTION Yes 31 22.6% No 106 77.4% Note: Patients may have multiple comorbidities, so counts and percentages for specific comorbidities sum to >100%. Percentages are calculated out of the total 137 patients. Table 3 details the frequency of reported clinical features. The most common symptoms were related to motor weakness: weakness/difficulty moving all 4 limbs (76.6%), difficulty walking (64.2%), and difficulty standing (60.6%). Generalized weakness was also common (47.4%). Bulbar symptoms like difficulty breathing (8.8%), facial weakness (7.3%), and dysphagia (2.9%) were present in a subset of patients. Table 3: Clinical Features (Symptoms) Clinical Feature Count (n)* Percentage (%)* WEAKNESS/DIFFICULTY IN MOVING ALL 4 LIMBS 105 76.6% D IN WALKING 88 64.2% D IN STANDING 83 60.6 % GENERALIZED WEAKNESS 65 47.4 % D IN gripping object 44 32.1 % WEAKNESS OF LL 27 19.7 % D IN BREATHING 12 8.8% FACIAL WEAKNESS 10 7.3% TRUNCAL WEAKNESS 10 7.3% DYSPHAGIA 4 2.9% D IN CLOSING EYE 3 2.2% FEVER 2 1.5% Note: Patients may present with multiple clinical features, so counts and percentages sum to >100%. Percentages are calculated out of the total 137 patients. Complications: As presented in Table 4, 24.1% of the cohort experienced complications. The most frequent complications were sensory neuropathy (9.5%) and neuropathic pain (7.3%). Other complications included Bell's Palsy, Heart Failure, PNES, Respiratory Failure, and Hydrocephalus, each occurring in a small number of patients. Table 4: Complication Count (n)* Percentage (%)* No reported complication 104 75.9 % (Patients with ≥1 complication) 33 24.1 % Specific Complications SENSORY NEUROPATHY 13 NEUROPATHIC PAIN 10 BELL'S PALSY 3 HEART FAILURE 2 PNES 1 RESPIRATORY FAILURE 1 Hydrocephalus 1 Note: Patients may have multiple complications, so counts and percentages for specific complications sum to >100%. Percentages are calculated out of the total 137 patients. Complications present Specific complications Need for Ventilation: Table 5 shows that 15 patients (10.9%) required mechanical ventilation during their hospital stay. Need for Ventilation Count (n) Percentage (%) YES 15 10.9% NO 122 89.1% Total Patients 137 100.0% Treatment Given: As detailed in Table 6, the most common treatments administered were supportive care (82.5%) and physiotherapy (67.9%). Specific GBS immunotherapies included intravenous immunoglobulin (IVIG) given to 35.0% of patients and plasmapheresis given to 2.9% of patients. Table 6: Treatment Given Treatment Given Count (n)* Percentage (%)* SUPPORTIVE RX 113 82.5% PHYSIOTHERAPY 93 67.9% IV ig given 48 35.0% PLASMAPHERESIS 4 2.9% Mortality: Remarkably, as shown in Table 7, no mortality (0%) was reported in this dataset within the captured timeframe. Table 7: Mortality Mortality Count (n) Percentage (%) No 137 100.0% Yes 0 0.0% Total Patients 137 100.0%

The demographic profile, showing a predominance of adults and males, is largely consistent with the known global epidemiology of GBS [1, 3]. The significant proportion of paediatric patients in this cohort (34.3%) is noteworthy and aligns with the recognition of GBS occurring across all age groups, including childhood [8, 10, 14]. The clinical presentation, characterized primarily by weakness/difficulty in moving all four limbs and significant impairment in standing and walking, reflects the typical motor involvement seen in GBS. The presence of bulbar symptoms (difficulty breathing, facial weakness, dysphagia) in a subset highlights the potential for more severe disease forms requiring vigilant monitoring and management. Approximately 29% of patients had underlying comorbidities, predominantly hypertension, diabetes, and thyroid disorders, reflecting the common health issues in the general population presenting to the hospital. The documented history of a preceding viral infection in 22.6% of cases aligns with the understanding of GBS as a post-infectious immune-mediated neuropathy [1, 12]. The identification of Post COVID infection in 7 patients (5.1%) further supports the growing evidence linking COVID-19 as a trigger for GBS, both globally and in India [7, 8, 9, 13, 18, 23, 25]. Complications were observed in about a quarter of the patients, with sensory neuropathy and neuropathic pain being the most common. These findings underscore the sensory nerve involvement that can occur in GBS and contribute to patient morbidity [1, 11]. The presence of other complications, including respiratory failure and heart failure, reinforces the systemic nature of severe GBS and the need for comprehensive critical care. The ventilation requirement rate of 10.9% indicates that a substantial minority of GBS patients in this setting experience significant respiratory muscle weakness. While within the lower range compared to some international cohorts, it highlights the need for critical care capacity. Treatment regimens were multimodal, with widespread use of supportive care and physiotherapy as cornerstones of management[6]. The administration of IVIG to 35.0% and Plasmapheresis to 2.9% of patients reflects the utilization of specific immunotherapies, which are crucial for accelerating recovery in moderate to severe GBS [2, 6]. The choice between IVIG and Plasmapheresis, and the criteria for their administration, were not available in this dataset. The most remarkable finding is the reported 0% mortality rate in this cohort of 137 patients. This is significantly lower than typical mortality rates reported for GBS globally, which usually range from 2% to 10%, even in high-resource settings [3, 12]. While this could potentially indicate excellent clinical management and outcomes at this center, it is crucial to interpret this finding cautiously due to the limitations of the retrospective dataset. Potential factors influencing this observation might include a cohort with predominantly milder disease presentations, successful early intervention and prevention of fatal complications, or limitations in data capture (e.g., not recording deaths occurring after hospital discharge). Without more detailed clinical severity scores upon admission, specific critical care interventions, and longer-term follow-up data, it is challenging to compare this mortality rate definitively with published literature and draw firm conclusions about factors contributing to such a low rate. Limitations: This study has several limitations inherent in its retrospective design. The dataset lacks detailed information on GBS severity scores (e.g., GBS disability scale) at different time points, specific diagnostic criteria used for GBS diagnosis (e.g., results of CSF analysis, nerve conduction studies, or EMG which are mentioned in the methods section but not provided in the results), and information about the specific GBS variant. The exact timing from symptom onset to hospital presentation and initiation of specific therapies (IVIG/Plasmapheresis) is not captured, which is critical for evaluating treatment effectiveness. The data does not include detailed longterm functional outcomes or capture mortality events occurring after hospital discharge. Furthermore, as a single-center study, the findings may not be generalizable to other regions or healthcare settings in India. Contribution and Future Directions: Despite these limitations, this study represents a valuable contribution by providing data on GBS characteristics and management from a rural tertiary care center in India, a region where such comprehensive reports are needed. It offers insights into the demographic profile, prevalent clinical features, the spectrum of complications, the proportion needing ventilatory support, and the use of standard therapies. The observed association with Post COVID infection and the low reported mortality are important findings that warrant further investigation. Future research should build on this foundation by establishing prospective GBS registries or conducting multi-center studies across India with standardized data collection protocols. This should include detailed clinical severity assessments, comprehensive diagnostic data (CSF, NCS/EMG), precise timing of interventions, and systematic short-term and long-term functional outcome assessments and mortality tracking. Such efforts are essential to gain a more complete and representative understanding of GBS in India, identify specific prognostic factors in this population, and inform the development and implementation of evidence-based, contextually appropriate management guidelines, thereby achieving the overall objectives of improving patient care.

This retrospective study of 137 GBS patients at a rural tertiary care center in Karamsad, India, provides valuable descriptive data on the clinical profile, complications, ventilation requirements, and treatment patterns. The findings highlight typical GBS presentations and the presence of comorbidities and preceding infections, including Post COVID. While limited by its retrospective nature and data detail, the study contributes to the understanding of GBS in India. The remarkably low reported mortality is a notable finding that requires validation with more comprehensive data and long-term follow-up in future studies. These efforts will be crucial for developing effective management strategies and improving patient outcomes for GBS in the Indian context.

1. Yuki, N., Hartung, H. P., & Katirji, B. (2012). Guillain-Barré syndrome. New England Journal of Medicine, 366(24), 2294-2304. 2. Hughes, R. A., Cornblath, D. R., & Griffin, J. W. (1999). Practice parameter:immunotherapy for Guillain-Barré syndrome: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 53(4), 533-539. 3. Willison, H. J., Jacobs, B. C., van Doorn, P. A., & van der Meche, F. G. (2016). Guillain Barré syndrome. Lancet, 388(10045), 717-727. 4. Garg, R. K., Gupta, V., Misra, U. K., & Kalita, J. (2016). Guillain-Barré syndrome in India: a systematic review of clinical features and outcome. Journal of the Peripheral Nervous System, 21(1), 3-14. 5. Shahrizaila, N., Yuki, N., & van Doorn, P. A. (2017). Guillain-Barré syndrome. Nature Reviews Disease Primers, 3(1), 17069. 6. Hughes, R. A., Swan, A. V., & van Doorn, P. A. (2014). Intravenous immunoglobulin for Guillain-Barré syndrome. Cochrane Database of Systematic Reviews, (10), CD002063. 7. Rafiei Tabatabaei, S., Rafiei Tabatabaei, R., & Rafiei Tabatabaei, M. (2021). Guillain-Barré syndrome in a child with COVID-19. Journal of Medical Case Reports, 15(1), 1-3. 8. Terencio, B. B. P., de Oliveira, S. K., de Oliveira, M. A., & de Oliveira, S. K. (2021). Guillain Barré syndrome in pediatric patients with COVID-19: a systematic review. Frontiers in Pediatrics, 9, 634722. 9. Goel, N., Mehndiratta, S., & Singh, A. (2021). Bioprofile and outcomes of post-COVID-19 Guillain-Barré syndrome in immunocompromised children. Indian Journal of Pediatrics, 88(10), 854-858. 10. Kanou, S., Ohno, S., & Hata, A. (2022). Guillain-Barré syndrome associated with COVID 19 in a child: a case report. BMC Neurology, 22(1), 1-4. 11. Dimachkie, M. M., & Barohn, R. J. (2016). Guillain-Barré syndrome and its variants. Lancet Neurology, 15(10), 1030-1044. 12. Van den Berg, B., Walgaard, C., Drenthen, J., Fokke, C., Jacobs, B. C., & van Doorn, P. A. prognosis. Nature Reviews Neurology, 14(11), 653-665. 13. Al Haboob AA. Miller Fischer and posterior reversible encephalopathy syndromes post COVID-19 infection. Pediatr Neurol. 2021;DOI: 10.1016/j.pediatrneurol.2021.10.003. 14. Kim Y, et al. A pediatric case of sensory predominant Guillain-Barré syndrome following COVID-19 vaccination. Child Neurol Open. 2022;9:2329048–221074549. 15. Van Doorn PA. Diagnosis, treatment and prognosis of Guillain-Barré syndrome (GBS). J Neurol. 2018;265(10):2353-2359. DOI: 10.1016/j.jneurol.2018.04.011. 16. Leman JD, et al. Guillain-Barré syndrome: expanding the concept of molecular mimicry. Trends Immunol. 2022;43:296–308. DOI: 10.1016/j.it.2022.02.003. 17. Guillain MG, et al. On a radiculoneuritis syndrome with hyperalbuminosis of cerebrospinal fluid without cellular reaction. Remarks on clinical and graphical 18. character of tendon reflexes. Ann Med Interne (Paris). 1999;150:24–32. Khan F, et al. COVID-19-associated Guillain-Barre syndrome: Postinfectious alone or neuroinvasive too? J Med Virol. 2021;93:6045–9. DOI: 10.1002/jmv.27159. 19. Post-traumatic (and postsurgical) Guillain-Barré Syndrome: a rare, but treatable entity. BMJ Case Rep [Internet]. Case Report: Delayed Guillain-Barré syndrome following trauma: A case series and manage considerations. Front Surg [Internet]. 2022;13:1001145. 20. Trauma-Related Guillain-Barré Syndrome: Systematic Review of an Emerging Concept. Front Neurol [Internet]. 2022;13:1001145. 21. Outcomes of patients presenting with Guillain-Barré Syndrome at a tertiary care center in India. J Clin Neurol [Internet]. 2021. (Note: This reference appears twice in the provided list, once as [22] and once without a number). 22. Guillain-Barré syndrome and COVID-19 vaccination: a systematic review and meta analysis. Vaccine [Internet]. 2022;40(43):6121-6131. (Note: This reference appears twice in the provided list, once as [23] and once without a number). Guillain-Barré syndrome after surgery: a literature review. J Clin Anesth [Internet]. 2020;64:109951. 23. Case Report: Guillain-Barré Syndrome Associated With COVID-19. Egypt J Neurol Psychiatr Sci [Internet]. 2021;28(2):109-114. 24. Neurophysiological and Ultrasound Correlations in Guillain Barré Syndrome and CIDP. J Clin Neurosci [Internet]. 2020;77:175-18