SARS-CoV-2 parainfection associated Landry -Guillain- Barre Syndrome (LGBS) in a term pregnant women: A clinical conundrum.

Abstract

Sir Guillain-Barre Syndrome (GBS) is a rare neurological disease that is characterized by progressive weakness in legs and arms, areflexia, or decreased tendon reflexes in weak limbs.[1] Evidence of GBS cases associated with SARS-CoV-2 infection has recently been reported.[2] Though GBS is considered mostly a post-infectious, immune-mediated disease, it might also occur during the infectious phase in some cases. Herein, we report first case of SARS-CoV-2 parainfection associated GBS in a term pregnant patient. A 22 year primigravida at 36 weeks of gestation, presented with acute onset of quadriparesis since 3 days and cough since 2 days. Patient c/o weakness in all four limbs, sudden onset, started distally in both lower limbs which progressed to involve upper limbs. On examination, she was tachypneic with respiratory rate of 32-34 breaths/min. She maintained saturation of 97% on ventimask at 0.4 fraction of inspired oxygen. On motor examination, in lower limb she had power of 2/5 at both ankle and knee joints. At hip joint, she had power of 1/5. In upper limb, she had power of 3/5 at both the shoulders and 4/5 at both the elbow joints. Deep tendon reflexes were absent. Her blood investigations were normal except for total serum bilirubin which was 3.2 mg/dl. She also tested SARS CoV-2 reverse transcriptase positive. Since she had no prior history of any gastrointestinal infection, she was diagnosed as SARS-CoV-2 parainfection associated Landry -Guillain- Barre Syndrome (LGBS) with respiratory involvement. In view of the worsening motor weakness and decline in respiratory functions, she was planned for urgent caesarean section. After preoxygenation, rapid sequence induction was done using thiopentone sodium and rocuronium and intubated with oral cuffed endotracheal tube with 7.0 mm internal diameter. She was ventilated using controlled mode with peak inspiratory pressure of 22 cm water, positive end expiratory pressure 5 and maintained on sevoflurane + oxygen at minimum alveolar concentration of 0.7-1. After delivery of baby, oxytocine infusion was started at 5 IU/h and injection fentanyl 50 μg was administered. Post-surgery she was shifted unreversed to COVID-19 intensive care unit (ICU). In ICU, she was administered intravenous immunoglobulins gram once a day (OD) for 4 days, low molecular weight heparin 0.6 ml OD, injection dexamethasone 6 mg twice a day, and Tablet Gabapentin 300 mg at night. Her CSF analysis showed total protein of 31.5 mg/dl and glucose levels of 68.9 mg/dL. During her ICU stay, she developed collapse and consolidation of left lung lower lobe with left sided pleural effusion, which resolved over next few days after she was tracheostomized. After 10 days of her ICU stay, she tested SARS-CoV-2 reverse transcriptase negative. Thereafter, she was shifted to non-COVID-19 ICU where she was gradually weaned from ventilatory support. Her nerve conduction study was performed which reported complete absence of compound muscle action potential (CAMP) with normal sensory nerve action potential (SNAP) suggestive of Acute Motor Axonal Polyneuropathy (AMAN) [Table 1]. She was shifted to medical ward for rehabilitative care. She was discharged from the hospital and was mobilized using wheel chair. There was complete return of motor power in upper limbs.Table 1: Nerve conduction study parameters of the patientTo the best of our knowledge, this is the first reported case of SARS-CoV-2 parainfection associated LGBS in term pregnant patient. She presented with short history of acute onset of muscle weakness accompanied by cough which gradually worsened and required assisted ventilation. As patient had already reached term, emergent caesarean section followed by management according to SARS-CoV-2 protocols was done. Guillain barre syndrome (GBS) worsens in postpartum period due to restoration of cellular immunity, with increase in delayed type of hypersensitivity which was adaptively depressed during pregnancy.[3] In an observational multicentre study, thirty GBS cases associated with COVID-19, stated COVID-19-associated GBS as being predominantly demyelinating and more severe than non-COVID-19 GBS.[4] Tekin et al.[5] have reported occurrence of LGBS in pregnant patient who had preceding SARS-CoV-2 infection. The patient developed muscle weakness in postpartum period, which recovered after receiving intravenous immunoglobulins. The prognosis of SARS-CoV-2 parainfection associated LGBS in term pregnant patient is still unclear and requires early recognition of danger signs for timely management and favorable outcome. Thus, clinical course of SARS-CoV-2 parainfection associated LGBS during pregnancy is highly complicated, due to presence of non-specific signs and symptoms and carries high risk of maternal morbidity. Early identification and multidisciplinary involvement are essential for diagnosis and good outcome. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.