GUILLAIN-BARRÉ SYNDROME FOLLOWING COVID-19 PNEUMONIA: ARE THEY RELATED?

Abstract

Listen

Translate article

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Guillain-Barre syndrome (GBS) is an immune-mediated polyneuropathy affecting the peripheral nervous system. Immune system activation in response to a viral or bacterial infection, which cross-reacts with the peripheral nerve components, is GBS's proposed mechanism. Epstein-Barr virus, campylobacter, cytomegalovirus, influenza, and mycoplasma are the most commonly associated infections with GBS development. Since the beginning of the coronavirus 2019 (COVID-19) pandemic, there have been isolated reports of the disease's neurological manifestations and sequelae. In early February 2020 itself, COVID-19 associated GBS has been reported from Italy and China. Here we are reporting the case of a GBS after severe COVID-19 pneumonia. CASE PRESENTATION: A 68-year- old Caucasian male with a history of obstructive sleep apnea, hypertension, and restless leg syndrome came to the hospital with worsening reparatory difficulty. He was diagnosed with COVID-19 pneumonia a week ago and was on remdesivir and dexamethasone therapy at home. At the time of presentation, he was found to be in respiratory failure, which eventually required intubation and mechanical ventilation. After spending 14 days on mechanical ventilation, the patient was extubated. His respiratory status significantly improved, but he was found to have confused mentation on day two after extubation. An MRI scan and EEG showed no significant abnormality. His confusion improved over the next two days, but he gradually developed bilateral upper and lower extremity symmetrical weaknesses with loss of deep tendon reflexes and touch sensation. The patient was also found to have alternating tachycardia and bradycardia around this period. The weakness progressed over the next week. CSF analysis revealed a protein level of 77mg/dL (normal: 8–43 mg/dL) with total nucleated cells of 3 (normal 0-8 ). CSF meningitis/encephalitis PCR panel for the 17 most common pathogens was negative (the panel did not have COVID-19). Nerve conduction studies were not done due to lack of availability. A diagnosis of GBS was made, and the patient was transferred to a higher center for plasmapheresis. DISCUSSION: COVID-19 leading to GBS does not come as a surprise;similar viruses, including Severe acute respiratory syndrome coronavirus and middle east respiratory syndrome coronavirus, had been reported to trigger GBS. If the CSF findings and autonomic nervous system involvement were absent, post-intensive care syndrome and critical care neuropathy might have been close differentials. There are isolated reports of blood transfusions leading to GBS;although unlikely, the patient's reception of convalescent plasma cannot be overlooked. The absence of nerve conduction studies also truncates the confidence of GBS diagnosis here. CONCLUSIONS: GBS may be triggered by COVID-19 infection, although more evidence is needed to establish the causation. REFERENCE #1: Caress JB, Castoro RJ, Simmons Z, Scelsa SN, Lewis RA, Ahlawat A, Narayanaswami P. COVID-19-associated Guillain-Barre syndrome: The early pandemic experience. Muscle Nerve. 2020 Oct;62(4):485-491. doi: 10.1002/mus.27024. Epub 2020 Aug 11. PMID: 32678460;PMCID: PMC7405390. REFERENCE #2: Rajdev K, Victor N, Buckholtz ES, Hariharan P, Saeed MA, Hershberger DM, Bista S. A Case of Guillain-Barre Syndrome Associated With COVID-19. J Investig Med High Impact Case Rep. 2020 Jan-Dec;8:2324709620961198. doi: 10.1177/2324709620961198. PMID: 32981333;PMCID: PMC7545753. REFERENCE #3: Scheidl E, Canseco DD, Hadji-Naumov A, Bereznai B. Guillain-Barre syndrome during SARS-CoV-2 pandemic: A case report and review of recent literature. J Peripher Nerv Syst. 2020 Jun;25(2):204-207. doi: 10.1111/jns.12382. Epub 2020 May 26. PMID: 32388880;PMCID: PMC7273104. DISCLOSURES: No relevant relationships by Arthur Cecchini, source=Web Response No relevant relationships by Bhavesh Gajjar, source=Web Response No relevant relationships by Rasheed Musa, source=Web Response No relevant relati nships by Akesh Thomas, source=Web Response