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BACKGROUND: Hypoxic brain injury results in severe disabilities that require extensive acute inpatient and outpatient rehabilitation to promote maximal functional and cognitive recovery. Brain hypoxemia can result from a multitude of causes, including but not limited to cardiac arrest, drug overdose, and/or shock. While recovery from a hypoxic brain injury alone can be challenging, dealing with concurrent debilitative diagnoses such as Guillain Barré Syndrome (GBS) further complicates the recovery and rehabilitation course. CASE REPORT: The current case study highlights the acute inpatient rehabilitation course of a 16 year old male who presented with cerebral hypoxia secondary to strangulation and subsequently developed GBS. Physical examination of the patient upon rehabilitation consult was inconsistent with a purely hypoxic brain injury, including the absence of rectal tone. This prompted further potential spinal cord injury evaluation and work up, with diagnostic testing confirmatory of GBS. RELEVANCE: This case is important as, to our knowledge from literature review, the first known documented instance of hypoxic brain injury complicated by GBS. Moreover, it highlights the importance of identifying all potential causes of functional disability, particularly when presented with physical exam findings inconsistent with chief diagnosis, in order to maximize functional recovery and rehabilitative gains during acute inpatient rehabilitation.

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In clinical practice, intrathecal baclofen (ITB) therapy is used to control spasticity. After initial placement of the ITB pump, clinicians incrementally increase the dose until effectiveness in alleviating spasms and spasticity is optimized. However, this case describes a 4-year-old male with Leigh syndrome who developed a paradoxical worsening of spasticity and pain with incremental increase of his ITB pump. In this rare genetic disease with a poor prognosis, an ITB pump was trialed and implanted and titrated upwards with initial improvement. However, his spasticity and pain then began to worsen with each dosage increase. Subsequently, his symptoms improved significantly when the dose was weaned. This is the first case that describes this paradoxical reaction in a pediatric population and discusses recommendations about how clinicians should safely titrate the pump for patient care.