key: cord-0684283-28l5vogi
authors: Khan, Farman; Sharma, Praveen; Pandey, Saurabh; Sharma, Deepak; V., Vijayavarman; Kumar, Neeraj; Shukla, Suruchi; Dandu, Himanshu; Jain, Amita; Garg, Ravindra K.; Malhotra, Hardeep S.
title: COVID‐19‐associated Guillain‐Barre syndrome: Postinfectious alone or neuroinvasive too?
date: 2021-07-06
journal: J Med Virol
DOI: 10.1002/jmv.27159
sha: 7a9a8ce236c91eb0b704e666439091e92fb01195
doc_id: 684283
cord_uid: 28l5vogi

Coronavirus disease 2019 (COVID‐19) has been shown to be associated with a lot of neurological complications, of whom Guillain‐Barre syndrome (GBS) is an important post‐infectious consequentiality. More than 220 patients with GBS have been reported thus far. We intend to share our experience with five patients of GBS where one of them had severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in the cerebrospinal fluid (CSF). This is the first‐ever report demonstrating the presence of SARS‐CoV‐2 in the CSF of an adult patient; a similar occurrence has recently been described in a pediatric patient. We wish to emphasize the fact that commonly GBS occurs as a result of a post‐infectious process but in a few cases where the symptoms of COVID‐19 and GBS occur concurrently, corresponding to the viremic phase, separate pathogenesis needs to be thought of. This para‐infectious nature is exemplified by the presence of virus in the cerebrospinal fluid of one of our patients. We review the neuroinvasive potential of SARS‐Cov‐2 in this regard and draw parallels with Cytomegalovirus, Zika virus, and Human Immunodeficiency virus‐associated occurrences of GBS.

the presence of SARS-CoV-2 in the CSF of an adult patient; a similar occurrence has recently been described in a pediatric patient. We wish to emphasize the fact that commonly GBS occurs as a result of a post-infectious process but in a few cases where the symptoms of COVID-19 and GBS occur concurrently, corresponding to the viremic phase, separate pathogenesis needs to be thought of. This para- We share our experience of these five patients and discuss in detail the pertinence of cerebrospinal fluid (CSF) positivity for SARS-Cov-2, observed in one of our cases. A summary of all cases is provided in Table 1 .

A 27-year-old gentleman (1-DE) had complaints of fever, sore throat, and myalgia for 5 days. In the presence of myalgia, an objective presence of weakness got masked until the difficulty in going upstairs and wearing footwear was noticed; the weakness progressed to involve the upper limbs over the next 3 days. By the 6 th day, he was unable to walk unaided and required support for routine chores.

There was no suggestion of bulbar or pulmonary involvement, bladder or bowel complaints, or cranial nerve deficits. On examination, the patient was alert and responsive. There was generalized hypotonia; the MRC sum score was 38/60, with loss of deep tendon response (DTR) at both ankles and hyporeflexia in the remainder.

Both plantars were flexor. He was detected positive by RT-PCR (naso-and oro-pharyngeal sample) for SARS-CoV-2; the clinical severity was labeled as moderate category. CSF examination revealed albuminocytologic dissociation (protein 185.7 mg/dL). Nerve conduction study (NCS) of all four limbs was suggestive of a motor axonal pattern. The patient was initiated on intravenous immunoglobulin (IVIg) at a dose of 0.4 gm/kg/day for 5 days; ivermectin and remdesivir were given as per protocol to manage COVID-19. The patient responded to treatment (walking with minimal support) and was discharged on the 14 th day.

A 35-year-old lady (2-SH), with no comorbidities, presented with complaints of fever and anosmia for 4 days; the fever subsided but after 9 days of onset of symptoms, she developed tingling in 

A 48-year-old lady (4-MA), a known case of constrictive pericarditis, presented with complaints of both lower limb paresthesias and weakness for 3 days, preceded by a history of fever and sore throat for a day. She was detected positive by RT-PCR for COVID-19; the | 6047 COVID-19. The point in question is of deciding whether the association fits into a postinfectious process or with a para-infectious process. For a postinfectious process, it is reasonably assumed that the time elapsed between the onset of symptoms of COVID-19 was sufficient enough to lead to the generation of antibodies demonstrating molecular mimicry and triggering an autoimmune process. In contrast, in a para-infectious process, such an interval is not present, and an alternative mechanism needs to be looked into. Regarding the latter, it may be assumed that either the symptoms were nonmanifest in nature and directly led to the dysimmune complication, or that the SARS-Cov-2 virus was capable of inflicting direct damage to radicles and nerves.

In at least four published cases, and the one that we discussed, COVID-associated GBS can be presumed to have occurred as a result of a para-infectious process. In four of these cases, the manifestation of GBS followed the onset of symptoms of COVID-19 by 1, Looking at the literature on COVID-19, it will be appropriate to assume that most patients with GBS occur as a result of an autoimmune process. The remainder, however, may fit into a parainfectious course suggestive of the neuroinvasive potential of SARS-CoV-2 virus, occurring during viremia. We, therefore, feel that such a possibility should be considered in these patients and CSF must be tested in all patients suspected of COVID-19-associated GBS for SARS-CoV-2 to have a better understanding of an alternative pathogenesis.

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How to cite this article

COVID-19-associated Guillain-Barre syndrome: Postinfectious alone or neuroinvasive too

ACKNOWLEDGMENT Funding was not involved in the conduct of this study.

The authors declare that there are no conflict of interests.

Concept and design of the study: