Guillain-Barré syndrome and COVID-19: association or coincidence

Bradycardia unresponded to atropin testing was successfully treated with therapeutic plasma exchange in a patient with severe COVID-19 complicated by Guillain-Barré syndrome: A case report

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has been an alarming situation worldwide for the past 2 years. The symptoms of coronavirus disease 2019 (COVID-19) are not only confined to the respiratory system but also affect a multitude of organ systems. Bradycardia associated with Guillain-Barré syndrome (GBS) is a rare autonomic and peripheral neurological complication of COVID-19. In this case report, we present the case of a 26-year-old man diagnosed with bradycardia associated with GBS after contracting COVID-19. Initially, this patient had the classical symptoms of COVID-19 and was hospitalized in the intensive care unit (ICU) for acute respiratory distress syndrome (ARDS). Then, he developed weakness in the lower extremities, diminished tendon reflexes, a loss of sensation without sphincter muscle disorders, and bradycardia. His bradycardia did not respond to atropine. The patient was treated concurrently with a high-flow nasal cannula, systemic corticosteroids, anticoagulation, and therapeutic plasma exchange (TPE) for COVID-19-induced ARDS, bradycardia, and GBS. His ARDS and bradycardia improved after the first cycle of TPE and medical treatment. After three cycles of TPE, the patient progressively recovered his muscle strength in the lower limbs and regained peripheral sensation. He was discharged from the hospital in stable condition after 4 weeks of hospitalization and was followed up after 6 months for cardiorespiratory and neurological complications. This case report elucidates the potential difficulties and challenges that physicians may encounter in diagnosing and treating COVID-19-induced bradycardia and GBS during the pandemic outbreak. However, the patient outcomes with the treatment combining the conventional treatment with therapeutic plasma exchange seem to be optimistic.

A case report of pediatric systemic lupus erythematosus with diffuse alveolar hemorrhage following COVID-19 infection: Causation, association, or chance?

RATIONALE

Diffuse alveolar hemorrhage (DAH) is a rare manifestation of childhood systemic lupus erythematosus (SLE) that can be life-threatening. Several reports have linked previous or concurrent coronavirus disease (COVID-19) infections with a high prevalence of autoimmune and autoinflammatory disorders.

PATIENT CONCERNS

We report a case of a 13-year-old female who presented with DAH due to SLE 2 months after a laboratory-confirmed severe COVID-19 infection.

DIAGNOSES

The patient was diagnosed with DAH due to SLE 2 months after a laboratory-confirmed severe COVID-19 infection.

INTERVENTIONS AND OUTCOMES

The patient was treated with intravenous methylprednisolone pulse, broad-spectrum antibiotics, and supportive measures. In addition, she received 6 sessions of plasma exchange and maintenance methylprednisolone therapy (2 mg/kg/day). The patient then improved and was discharged on prednisolone, hydroxychloroquine, and azathioprine.

LESSONS

We suggest plasmapheresis be considered a treatment for SLE-associated DAH in the context of active disease when conventional treatment has failed to induce a rapid response. In addition, further studies are needed to assess the role of COVID-19 as an autoimmune disease trigger, particularly for SLE.

COVID-19 and the Peripheral Nervous System. A 2-year review from the pandemic to the vaccine era

Increasing literature has linked COVID‐19 to peripheral nervous system (PNS) diseases. In addition, as we move from the pandemic to the vaccination era, literature interest is shifting towards the potential association between COVID‐19 vaccines and PNS manifestations. We reviewed published literature on COVID‐19, COVID‐19 vaccines and PNS manifestations between 1 January 2020 and 1 December 2021. For Guillain‐Barré syndrome (GBS), isolated cranial neuropathy (ICN) and myositis associated with COVID‐19, the demographic, clinical, laboratory, electrophysiological and imaging features were included in a narrative synthesis. We identified 169 studies on COVID‐19‐associated complications, including 63 papers (92 patients) on GBS, 29 papers (37 patients) on ICN and 11 papers (18 patients) on myositis. Additional clinical phenotypes included chronic inflammatory demyelinating polyneuropathy, vasculitic neuropathies, neuralgic amyotrophy, critical care‐related complications, and myasthenia gravis. PNS complications secondary to COVID‐19 vaccines have been reported during randomized clinical trials, in real‐world case reports, and during large‐scale surveillance programs. These mainly include cases of GBS, Bell's palsy, and cases of neuralgic amyotrophy. Based on our extensive review of the literature, any conclusion about a pathophysiological correlation between COVID‐19 and PNS disorders remains premature, and solely supported by their temporal association, while epidemiological and pathological data are insufficient. The occurrence of PNS complications after COVID‐19 vaccines seems limited to a possible higher risk of facial nerve palsy and GBS, to a degree that widespread access to the ongoing vaccination campaign should not be discouraged, while awaiting for more definitive data from large‐scale surveillance studies.

Occupational and Physical Therapy Strategies for the Rehabilitation of COVID-19 Related Guillain-Barré Syndrome in the Long-Term Acute Care Hospital Setting: A Case Report

BACKGROUND

While several reports have described the diagnosis and treatment of patients with COVID-19 associated Guillain-Barré Syndrome (GBS), there is a paucity of literature describing the occupational and physical therapy strategies used in the long-term acute care hospital (LTACH) setting to rehabilitate these patients.

OBJECTIVE

A 61 year-old male was admitted to an LTACH for the rehabilitation of GBS following COVID-19 infection and intravenous immunoglobulin treatment.

METHODS

Rehabilitation in the LTACH setting uses a variety of skilled treatment interventions to meet patient driven goals and maximize their function to the highest level possible in preparation of their discharge to a subacute or homecare setting. In this case, this was accomplished through individual occupational and physical therapy sessions, occupational and physical therapy co-treatment sessions, and targeted group therapy sessions focused on leg, arm, and fine motor coordination exercises.

RESULTS

With the occupational and physical therapy standard of care, the patient's improvement was demonstrated by several outcome measures including manual muscle testing, range-of-motion, grip-strength, and the Activity Measure for Post-Acute Care. The patient was successfully rehabilitated and returned to the community after presenting with COVID-19 associated GBS.

CONCLUSIONS

This report highlights the complex rehabilitation needs patients require to regain independence after diagnosis of COVID-19 associated GBS.

Guillain Barre Syndrome as a Complication of COVID-19: A Systematic Review

BACKGROUND

In January 2020, the first case of Guillain Barre syndrome (GBS) due to COVID-19 was documented in China. GBS is known to be postinfectious following several types of infections. Although causality can only be proven through large epidemiological studies, we intended to study this association by a thorough review of the literature.

METHODS

We searched PubMed, EMBASE, and Google scholar and included all papers with English or Spanish full text and original data of patients with GBS and recent COVID infection. Variables of interest were demographics, diagnostic investigations, and the latency between arboviral and neurological symptoms. Further variables were pooled to identify GBS clinical and electrophysiological variants, used treatments, and outcomes. The certainty of GBS diagnosis was verified using Brighton criteria.

RESULTS

We identified a total of 109 GBS cases. Ninety-nine cases had confirmed COVID-19 infection with an average age of 56.07 years. The average latency period between the arboviral symptoms and neurologic manifestations for confirmed COVID-19 cases was 12.2 d. The predominant GBS clinical and electromyography variants were the classical sensorimotor GBS and acute demyelinating polyneuropathy respectively. Forty cases required intensive care, 33 cases required mechanical ventilation, and 6 cases were complicated by death.

CONCLUSIONS

Studies on COVID-19-related GBS commonly reported sensorimotor demyelinating GBS with frequent facial palsy. The time between the onset of infectious and neurological symptoms suggests a postinfectious mechanism. Early diagnosis of GBS in COVID-19 patients is important as it might be associated with a severe disease course requiring intensive care and mechanical ventilation.

Reworsening of Recurrent Guillain-Barré Syndrome Triggered by COVID-19 Infection

Introduction:

Guillain-Barré Syndrome (GBS) is an acute, immune-mediated, generalized polyradiculoneuropathy often triggered by a bacterial or viral infection, vaccination, or surgery. During the SARS-CoV-2 pandemic, some patients were reported with GBS associated COVID-19 infection.

Case Presentation:

We report, herein, a patient who had a recurrent GBS after forty years. Intravenous immunoglobulins (IVIg) induced improvement, but her condition worsened suddenly after twenty days, coinciding with a COVID-19 infection. A second IVIg cycle was administered, and she improved again.

Conclusion:

The take-home message is that in the current pandemic, any re-worsening or lack of improvement after appropriate treatment of GBS or possibly other autoimmune neurological diseases must be checked to determine if it is related to COVID-19 infection.

Acute Inflammatory Demyelinating Polyneuropathy With Bowel and Bladder Incontinence Following COVID-19 Infection

Coronavirus disease 2019 (COVID-19) has led to a global pandemic with the recent demonstration of several neurological manifestations. While there are limited reports of neurologic involvement in the context of COVID-19 infection, recent evidence has established the neuroinvasive potential of the virus.

A 57-year-old man was diagnosed with COVID-19 via a polymerase chain reaction test and treated as an outpatient with a combination of prednisone and azithromycin. Nine days after his initial diagnosis, he was admitted to the intensive care unit for acute respiratory failure where he required high-flow oxygen support at a maximum of 60 L/minute. Ten days after his admission to the intensive care unit, he was discharged requiring no oxygen at rest, but 2-3 L/minute with exertion. Nine days after his discharge, he was readmitted with a six-day history of bilateral lower extremity weakness, low back pain, diminished sensation, bowel and bladder incontinence, and decreased rectal sensation and tone. Evaluation for cauda equina syndrome was unremarkable; however, cervical magnetic resonance imaging revealed severe central cervical stenosis of C3-4 and C4-5 with spinal cord flattening and intraparenchymal T2 hyperintensity. The examination was notable for muted reflexes in the bilateral lower extremities, T10 sensory level, decreased rectal tone, and ambulation with a walker. Cerebrospinal fluid analysis revealed an albuminocytologic dissociation. Treatment with intravenous dexamethasone and immunoglobulin resulted in partial motor resolution and complete resolution of his bowel and bladder incontinence within three days of treatment.

In the face of this novel global pandemic, surgeons and clinicians should carefully evaluate patients presenting with neurologic deficits and ensure a thorough examination to accurately identify the appropriate etiology for a neurologic deficit.

Treatment Options for COVID-19-Related Guillain-Barré Syndrome: A Systematic Review of Literature

BACKGROUND

Central nervous system complications are reported in an increasing number of patients with Coronavirus Disease 2019 (COVID-19). COVID-19-related Guillain-Barré syndrome (GBS) is of particular importance given its association with higher mortality rates and prolonged respiratory failure.

REVIEW SUMMARY

We conducted a systematic review of published cases for COVID-19-related GBS, and provide a summary of clinical management strategies for these cases. Sixty-three studies, including 86 patients, were included. Seventy-six cases with reported outcome data were eligible for the outcome analysis. Ninety-nine percent of patients were diagnosed with COVID-19 before diagnosis of GBS (median: 14 d prior, interquartile range: 7 to 20). Intravenous immunotherapy (intravenous immunoglobulin: 0.4 g/kg/d for 5 d) was the most frequently used treatment approach. The review indicated that the outcome was not favorable in 26% of cases (persistent neurological deficits). A mortality rate of 3.5% was observed in patients with COVID-19-related GBS.

CONCLUSIONS

Although evidence to support specific treatments is lacking, clinicians should consider the benefits of immunotherapy and plasma exchange in addition to the standard antimicrobial and supportive therapies for patients who meet the diagnostic criteria for acute sensory and motor polyradiculoneuritis. Intravenous immunoglobulin treatment alone is not shown to result in improved outcomes or mortality. More extensive studies aimed at exploring the neurological manifestations and complications of COVID-19 and distinctive treatment options for COVID-19-related GBS are warranted.

Age-Associated Neurological Complications of COVID-19: A Systematic Review and Meta-Analysis

The outbreak of the novel and highly infectious severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in hundreds of millions of infections and millions of deaths globally. Infected individuals that progress to coronavirus disease-19 (COVID-19) experience upper and lower respiratory complications that range in severity and may lead to wide-spread inflammation and generalized hypoxia or hypoxemia that impacts multiple organ systems, including the central and peripheral nervous systems. Since the SARS-CoV-2 outbreak, multiple reports continue to emerge that detail neurological symptoms, ranging from relatively mild (e.g., impaired taste and/or smell) to severe (e.g., stroke), suggesting SARS-CoV-2 may be neurotropic and/or contribute to nervous system injury through direct and/or indirect mechanisms. To gain insight into the types of neurological complications associated with SARS-CoV-2 infection and their possible relationship with age, sex, COVID-19 severity, and comorbidities, we performed a systematic review of case reports and series published in 2020 - April 4, 2021 of infected patients with neurological manifestations. Meta-analyses were conducted using individual patient data from reports where these data could be extracted. Here, we report neurological injury occurs across the lifespan in the context of infection, with and without known comorbidities, and with all disease severities, including asymptomatic patients. Older individuals, however, are more susceptible to developing life-threatening COVID-19 and cerebrovascular disease (CVD), such as stroke. A mild but inverse correlation with age was seen with CNS inflammatory diseases, such as encephalitis, as well as taste and/or smell disorders. When reported, increased age was also associated with comorbid cardiovascular risk factors, including hypertension, diabetes mellitus, and lipid disorders, but not with obesity. Obesity did correlate with development of critical COVID-19. Discussion into potential pathophysiological mechanisms by which neurological symptoms arise and long-term consequences of infection to the nervous system is also provided.

Axonal Guillain-Barre syndrome associated with SARS-CoV-2 infection in a child

The relation between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and demyelinating Guillain-Barre syndrome (GBS) has been defined. We aim to report the clinical features of a child with axonal GBS associated with SARS-CoV-2. A 6-year-old male presented with symmetric ascending paralysis progressed over a 4-day course and 2 days of fever. He had bilateral lower and upper limb flaccid weakness of 1/5 with absent deep tendon reflexes. He had severe respiratory muscle weakness requiring invasive mechanical ventilation. On admission, SARS-CoV-2 returned as positive by real-time polymerase chain reaction on a nasopharyngeal swab. Cerebrospinal fluid analysis showed elevated protein without pleocytosis. He was diagnosed with GBS associated with SARS-CoV-2 infection. The nerve conduction study was suggestive of acute motor axonal neuropathy. Ten consecutive therapeutic plasma exchange sessions with 5% albumin replacement followed by four sessions on alternate days were performed. On Day 12, methylprednisolone (30 mg/kg/day for 5 days) was given. On Day 18, intravenous immunoglobulin (2 g/kg/day) was given and repeated 14 days after due to severe motor weakness. On Day 60, he was discharged from the hospital with weakness of neck flexor and extensor muscles of 3/5 and the upper limbs and the lower limbs of 2/5 on home-ventilation. Our patient is considered to be the youngest patient presenting with a possible para-infectious association between axonal GBS and SARS-CoV-2 infection. The disease course was severe with a rapid progression, an earlier peak, and prolonged duration in weakness as expected in axonal GBS.

Rehabilitation and COVID-19: a rapid living systematic review by Cochrane Rehabilitation Field updated as of December 31st, 2020 and synthesis of the scientific literature of 2020

INTRODUCTION

COVID-19 infection significantly increased mortality risk and the burden of disability in most survivors, regardless of symptom severity at onset. The rehabilitation needs of people infected are receiving growing attention, as evidenced by the increasing number of publications, including those addressing the chronic consequences of infection. This rapid living systematic review reports the evidence published in November and December 2020 and summarises the entire body of literature on rehabilitation in COVID-19 patients published in 2020.

EVIDENCE ACQUISITION

This update was performed using the methodology reported by the second edition conducted by Cochrane Rehabilitation REH-COVER Action. We searched PubMed, Embase, CINAHL, Scopus, Web of Science, and Pedro databases. Papers related to COVID-19 and rehabilitation were retrieved and summarised descriptively.

EVIDENCE SYNTHESIS

The search retrieved 4441 studies. After the removal of duplicates and the screening for title and abstract, we retained 105 studies. Of these, we included 54 in the qualitative synthesis of this update. According to OCEBM 2011 levels of evidence table, most studies (64.8%) fall within the category of level 4 evidence. Up to 40.7% of papers included COVID-19 patients in the postacute phase. In 2020, our rapid living systematic review included 230 studies; most of these (73.9%) were level 4 studies, 25.7% were level 3, and only one study was level 2. The evidence level improved over time. While most studies (44.8%) included patients with acute COVID-19, we observed a gradual increase in the number of reports about chronic symptoms and the long-term consequences of the infection.

CONCLUSIONS

The update of the rapid living systematic review by Cochrane Rehabilitation Field demonstrates an increase in the level of evidence of studies addressing the rehabilitation needs associated with COVID-19 infection. Although most studies are still case reports/series, there is a trend towards conducting prospective investigations of the early natural history of the disease (first months post onset). High-quality-level studies on the efficacy of rehabilitation, and long-term monitoring of the disease and its sequelae are yet to emerge.

COVID-19 infection presented as Guillain-Barre Syndrome: Report of two new cases and review of 116 reported cases and case series

BACKGROUND

/Aims: Corona virus disease 2019 (COVID 19) is a pandemic infectious disease of 2020, which often presents with respiratory and gastrointestinal symptoms. The behavior of the virus and its full clinical picture has not been fully studied yet. Many case reports and case series have been running in order to elaborate different presentations and associations. Pulmonary and gastrointestinal features of COVID-19 infection are well outlined; however, neurological manifestations are less defined.

CASE PRESENTATION

We report two adult cases of COVID-19 infection presented with acute Guillain-Barre Syndrome (GBS), and a literature review on the causal association between COVID-19 and GBS.

CONCLUSION

Our two case reports in addition to literature review of 116 published cases may help offer insight into the clinical course of COVID-19 infection. Our two COVID-19 patients presented with neurological manifestations of GBS which were not preceded with any respiratory, gastrointestinal or other systemic infection. This leads us to raise the possibility of establish direct causal association between COVID-19 infection and GBS. Physicians should have high clinical suspicions when encounter GBS patient during the current COVID-19 pandemic and consider co-existence of COVID-19 infection that may warrant SARS-CoV-2 testing, isolation precautions, and specific treatment for Covid-19 infection.