Post Covid-19 guillain barre syndrome

Dear Editor, The neurological complications of the present COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 are well documented.[1] As of the 10thSeptember 2020, the global SARS-CoV2 infections have crossed 27 million with over 4.3 million cases and 73,000 death from India. There are a few reports of neurological complications of COVID-19 from India; however, post-COVID-19 Guillian–Barre Syndrome (GBS) as an immune-mediated phenomenon has not been reported.[234] A 60-year-old man with a history of diabetes and hypertension on treatment was evaluated for cough 2.5 months earlier. Nasal swab RT-PCR was positive for SARS-CoV2. Repeat nasal swab tests were negative on day 16. Nine weeks after his last negative test, he developed left leg weakness and buckling at the knees. Over the next 3 days, he developed an asymmetrical lower limb weakness [Left > right], unsteadiness, and paresthesias of all limbs. On examination, he had grade 4/5 MRC scale power in his upper limbs, 1/5 power in the proximal lower limbs, upper limb ataxia, bifacial weakness, and global areflexia without any sensory signs. CSF study showed an albumin-cytologic dissociation [5 WBC's with elevated protein- 187.3 mg/dL]. CSF RT-PCR for SARS-CoV2 was not performed as it was 10-11 weeks after his acute illness. Nerve conduction studies showed absent F waves, prolonged distal latencies, and slowed conduction velocities. His routine blood tests were normal, LDH- 311 U/L (125–220, ferritin 88 ng/ml (18.7–323), and serology was non-reactive for HIV, Hepatitis B and C viruses. He was diagnosed to have postinfectious GBS and treated with IVIg at 2 gm/Kg over 5 days along with intensive physiotherapy. Over the next 10 days, he worsened to MRC grade 2/5 power in all limbs with limb ataxia and areflexia. He also developed neck and truncal weakness. By day 19, he started improving [grade 3/5 power]. An MRI whole-body STIR muscle imaging was normal. Serum CPK levels were normal. An EMG on day 19 was essentially normal. On day 22, his serum ganglioside antibody panel testing by indirect ELISA were positive for IgG-Gd1b antibodies. His Anti-SARS-CoV2 antibodies [Roche™ Anti-SARS-CoV-2 assay using the double antigen sandwich (DAGS) format] were also highly reactive (60.3) {Biological reference interval > 1.0}, suggesting a post-COVID convalescent phase. This assay detects high-affinity IgM, IgA, and IgG antibodies which appear in the 2nd week of illness. It uses an electrochemiluminescence immunoassay analyzer (ECLIA) and is comparable to an EDI™ ELISA test.[5] By day 27, he was able to sit without support. The incidence of neurological complications in COVID-19 approaches ~ 36% in large series [Figure 1].[6] Both cranial and peripheral neuropathies [including GBS and Miller Fisher syndrome] have been documented in the acute phase of COVID-19 illness.[78] The neuromuscular complications are linked to direct neural invasion of the coronavirus, infective leptomeningitis or to para or postinfectious immune-mediated phenomena. Most reports of GBS in COVID-19 is documented with acute SARS-CoV2 infection. Most patients have presented in the acute phase of the illness with a mean period of ~ 11 days from the onset of acute viral illness.[9] In some patients, GBS alone without any other symptoms has been the presenting manifestation of COVID-19. COVID-GBS cases were similar to non-COVID-19 GBS, showing a demyelinating pattern on electrophysiological studies, albumino-cytologic dissociation in the CSF and negative for SARS-CoV-2 RT-PCR on CSF.[10] Tested sera were negative for serum anti-ganglioside antibodies in most patients. Like our patient, a few cases showed serum anti-GD1b ganglioside antibodies with Miller–Fisher syndrome.Figure 1: Shows the clinical picture of COVID-19 infection and the course of our patient correlated with the week of illnessMost reports have shown a consistent response to intravenous immunoglobulin or plasma exchange with improvement within 8 weeks in the majority. The vast majority of reports of GBS with COVID-19 have been para-infectious and post-infectious GBS is rare.[1112] As experts have predicted an uptick in post-infectious immune-mediated neurological complications after the peak of the pandemic, our report is noteworthy in its documentation of a post-COVID-19 GBS. To the best of our knowledge, this is the first report of a post-COVID-19 immune-mediated neurological disorder from India. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Abstract licence: CC BY-NC-SA

10 more references, whose wording the paper’s licence keeps private.

A person counts once a day per paper. We keep no cookie and no address: a reader is a hash that changes every day. Any month under five reads shows no number.