Guillain-Barré syndrome in SARS-CoV-2 infection: an instant systematic review of the first six months of pandemic

Cold case: COVID-19-triggered type 1 cryoglobulinemia

A 42-year-old male was referred to the internal medicine department because of renal failure and persistent malaise after a recent SARS-CoV-2 infection. Blood results showed anemia and severe renal insufficiency (hemoglobin of 10.3 g/dL and a creatinine of 2.19 mg/dL). Additional tests revealed a type I cryoglobulinemia with a cryoprecipitate composed of dual IgM (kappa and lambda). Further investigations on the cryoprecipitate revealed that the immunoglobulins were directed against SARS-CoV-2 antigens. In the meanwhile, our patient noticed improvement of his symptoms accompanied by resolution of laboratory abnormalities. Three months later, the cryoglobulin could no longer be detected.Type 1 cryoglobulinemia is usually associated with lymphoproliferative disorders and is characterized by various symptoms caused by cryoprecipitates occluding small blood vessels. This is, to our knowledge, the first case of type I cryoglobulinemia with proven precipitation of SARS-CoV-19 antibodies. COVID-19 induced cryoglobulinemia appears to have a mild disease course and to be self-limiting upon viral clearance.

The Impact of COVID-19 on the Guillain-Barré Syndrome Incidence

Despite the fact that the global COVID-19 pandemic has officially ended, we continue to feel its effects and discover new correlations between SARS-CoV-2 infection and changes in the organism that have occurred in patients. It has been shown that the disease can be associated with a variety of complications, including disorders of the nervous system such as a characteristic loss of smell and taste, as well as less commonly reported incidents such as cranial polyneuropathy or neuromuscular disorders. Nervous system diseases that are suspected to be related to COVID-19 include Guillain-Barré syndrome, which is frequently caused by viruses. During the course of the disease, autoimmunity destroys peripheral nerves, which despite its rare occurrence, can lead to serious consequences, such as symmetrical muscle weakness and deep reflexes, or even their complete abolition. Since the beginning of the pandemic, case reports suggesting a relationship between these two disease entities have been published, and in some countries, the increasing number of Guillain-Barré syndrome cases have also been reported. This suggests that previous contact with SARS-CoV-2 may have had an impact on their occurrence. This article is a review and summary of the literature that raises awareness of the neurological symptoms' prevalence, including Guillain-Barré syndrome, which may be impacted by the commonly occurring COVID-19 disease or vaccination against it. The aim of this review was to better understand the mechanisms of the virus's action on the nervous system, allowing for better detection and the prevention of its complications.

Electrodiagnostic methods to verify Guillain-Barré syndrome subtypes in Istanbul: A prospective multicenter study

BACKGROUND AND AIMS

This study aimed to identify the clinical characteristics and electrodiagnostic subtypes of Guillain-Barré syndrome (GBS) in Istanbul.

METHODS

Patients with GBS were prospectively recruited between April 2019 and March 2022 and two electrodiagnostic examinations were performed on each patient. The criteria of Ho et al., Hadden et al., Rajabally et al., and Uncini et al. were compared for the differentiation of demyelinating and axonal subtypes, and their relations with anti-ganglioside antibodies were analyzed.

RESULTS

One hundred seventy-seven patients were included, 69 before the coronavirus disease 2019 pandemic (April 2019-February 2020) and 108 during the pandemic (March 2020-March 2022), without substantial changes in monthly frequencies. As compared with the criteria of Uncini et al., demyelinating GBS subtype diagnosis was more frequent according to the Ho et al. and Hadden et al. criteria (95/162, 58.6% vs. 110/174, 63.2% and 121/174, 69.5%, respectively), and less frequent according to Rajabally et al.'s criteria (76/174, 43.7%). Fourteen patients' diagnoses made using Rajabally et al.'s criteria were shifted to the other subtype with the second electrodiagnostic examination. Of the 106 analyzed patients, 22 had immunoglobulin G anti-ganglioside antibodies (14 with the axonal subtype). They had less frequent sensory symptoms (54.5% vs. 83.1%, p = 0.009), a more frequent history of previous gastroenteritis (54.5% vs. 22.9%, p = 0.007), and a more severe disease as compared with those without antibodies.

INTERPRETATION

Serial electrodiagnostic examinations are more helpful for accurate subtype diagnosis of GBS because of the dynamic pathophysiology of the disease. We observed no significant increase in GBS frequency during the pandemic in this metropolis.

Guillain-Barré syndrome and SARS-CoV-2 infection: a systematic review and meta-analysis on a debated issue and evidence for the 'Italian factor'

BACKGROUND AND PURPOSE

The association between Guillain-Barré syndrome (GBS) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is debated. This study reappraises, after three pandemic years, the epidemiological data and the features of GBS in SARS-CoV-2 patients.

METHODS

A systematic review and meta-analysis of case reports/series and cohort studies published between 1 January 2020 and 19 April 2023 was performed.

RESULTS

In all, 209 case reports/series (304 patients) and 26 cohort studies were included. The risk of GBS in northern Italy during the first pandemic wave was 2.85 times increased (95% confidence interval [CI] 1.54; 5.25) whereas in some countries the risk during the first pandemic year was 0.17 times reduced (risk ratio 0.83, 95% CI 0.75; 0.93). The incidence of GBS in SARS-CoV-2 Italian hospitalized cohorts was 8.55 per 1000 (95% CI 5.33; 12.49) with an estimated incidence of 0.13 GBS per 1000 in the SARS-CoV-2 infected population. In European cohorts the pooled rate of GBS with SARS-CoV-2 infection was 61.3% of the total. GBS patients with SARS-CoV-2 infection showed more frequently, but not differently from non-infected patients, the classical clinical presentation and the demyelinating subtype. Cranial nerves were more frequently involved in SARS-CoV-2 infected patients.

CONCLUSIONS

An increased risk of GBS occurred in northern Italy during early COVID-19 pandemic. The recognition of the 'Italian factor' reconciles contrasting results of the epidemiological studies. The slightly reduced GBS risk in other countries and the relatively high frequency of GBS associated with SARS-CoV-2 infection can be explained by the adopted health measures that decreased the circulation of other GBS infective antecedents.

Retrospective analysis of COVID-19 patients with Guillain-Barre, Miller-Fisher, and opsoclonus-myoclonus-ataxia syndromes-a case series

BACKGROUND

In accordance with the rising number of SARS-CoV‑2 infections, reports of neurological complications have also increased. They include cerebrovascular diseases but also immunological diseases such as Guillain-Barre syndrome (GBS), Miller-Fisher syndrome (MFS), and opsoclonus-myoclonus-ataxia syndrome (OMAS). While GBS and MFS are typical postinfectious complications, OMAS has only recently been described in the context of COVID-19. GBS, MFS, and OMAS can occur as para- and postinfectious, with different underlying pathomechanisms depending on the time of neurological symptom onset. The study aimed to describe clinical features, time between infection and onset of neurological symptoms, and outcome for these diseases.

METHODS

All COVID-19 patients treated in the neurological ward between January 2020 and December 2022 were screened for GBS, MFS, and OMAS. The clinical features of all patients, with a particular focus on the time of onset of neurological symptoms, were analyzed.

RESULTS

This case series included 12 patients (7 GBS, 2 MFS, 3 OMAS). All GBS and one MFS patient received immunomodulatory treatment. Three patients (2 GBS, 1 OMAS) had a severe COVID-19 infection and received mechanical ventilation. In patients with OMAS, only one patient received treatment with intravenous immunoglobulin and cortisone. The remaining two patients, both with disease onset concurrent with SARS-COV‑2 infection, recovered swiftly without treatment. In all subgroups, patients with concurrent onset of neurological symptoms and COVID-19 infection showed a trend toward shorter disease duration.

CONCLUSION

All patient groups displayed a shorter disease duration if the onset of neurological symptoms occurred shortly after the COVID-19 diagnosis. In particular, both the OMAS patients with symptom onset concurrent with COVID-19 showed only abortive symptoms followed by a swift recovery. This observation would suggest different pathomechanisms for immune-mediated diseases depending on the time of onset after an infection.

Guillain-Barré syndrome post-SARS-CoV-2 vaccine: a systematic review and data analysis on its clinical, laboratory, electrophysiological, and radiological features

Introduction

Guillain-Barré syndrome (GBS) is a rare disease that affects almost 0.8-1.9 cases per 100,000 people worldwide every year. This is the most prevalent cause of subacute flaccid paralyzing illness today. It is a subacute inflammatory demyelinating polyradiculoneuropathy; the typical scenario involves ascending symmetrical flaccid paralysis, but in some circumstances, sensory, autonomic, and cranial neuropathy may also be involved. Several vaccines have been found to have complications since the previous century. Numerous case reports of GBS in the literature have been reported following COVID-19 vaccines in recent times.

Objective

This study aimed to conduct a comprehensive examination of GBS cases that have been reported after COVID-19 vaccines; to analyze the descriptive statistical analysis of data gathered regarding clinical, laboratory, electrophysiological, and radiological characteristics; to discuss, based on the available evidence, whether the disease has a preference for a particular vaccine type; and to speculate on the potential pathogenesis.

Methodology

This review has been carried out by recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Result

Reviewing 60 case reports illustrated that most of them are from the USA (18.1%) and the majority of affected individuals were males (60%). The results favored the association between vector-based SARS-CoV-2 vaccine, particularly AstraZeneca vaccine, and the GBS. The mean of symptoms onset is 11.4 days. The results of diagnostic tests such as LP are consistent mostly with albumin-cytological dissociation (81.81%), where brain and spine MRI was unremarkable in 59.52%. Regarding electrodiagnostic tests, AIDP is the most common variant (61.81%). The management was not consistent among the case reports. However, IVIG is the most frequent way of treating these patients (68.33%). The functional outcome was documented in 47 patients; 65% improved with medical management.

Conclusion

This study aimed to conduct a systematic review of reported cases of GBS following COVID-19 vaccines and descriptive statistical analysis of collected data on clinical, laboratory, electrophysiological, and radiological features, to discuss, based on available results, whether the disease has a predilection to a specific vaccine type and to speculate the potential pathogenesis.

What Is the Impact of the Novel Coronavirus and the Vaccination on Guillain-Barre Syndrome?

The COVID-19 pandemic, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has resulted in devastating medical and economic consequences worldwide over the past 3 years. As the pandemic enters a new stage, it is essential to consider the potential impact on rare diseases such as Guillain-Barre syndrome (GBS), which has been intimately associated with COVID-19 since the first COVID-19-related GBS case was reported in January 2020. There are notable differences between COVID-19-related GBS and GBS without COVID-19 in terms of diagnostic types and clinical manifestations. Furthermore, with the widespread administration of COVID-19 vaccines, there have been reports of GBS occurring shortly after vaccination, which requires close attention despite its rarity. This review also explores the vaccines associated with heightened GBS risks, offering insights that may guide vaccination policies and clinical practice. To provide a visual summary of these findings, we have included a graphical abstract. This article will discuss the characteristic manifestations of GBS patients after being positive for the novel coronavirus and the safety of several COVID-19 vaccines. Firstly, this article comprehensively expounds and discusses the epidemiological aspects of novel coronavirus-related GBS. For example, from the perspective of the same population, the expected incidence of GBS in the COVID-19-positive population (persons/100,000 persons/ year) is about 43 times that of the COVID-19-negative population, and the incidence of GBS is significantly increased. Secondly, the clinical characteristics of COVID-19-negative GBS patients and SARS-CoV-2-GBS (SC2-GBS) patients were summarized and compared. Thirdly, this article reviews GBS cases in the current adverse events after COVID-19 vaccination and analyzes and discusses from multiple perspectives, such as the incidence of GBS events, the age proportion of patients, and the interval of onset.

Case Report: Four cases of SARS-CoV-2-associated Guillain-Barré Syndrome with SARS-CoV-2-positive cerebrospinal fluid detected by metagenomic next-generation sequencing: a retrospective case series from China

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is often absent or at low levels in the cerebrospinal fluid (CSF) of patients with previous SARS-CoV-2-associated Guillain-Barré syndrome (GBS). This has led to speculation that SARS-CoV-2-associated GBS is more likely mediated by post-infectious immunity or a parainfection. This understanding has influenced the development of treatment regimens for SARS-CoV-2-associated GBS. This paper reports our experience with four Chinese patients with SARS-CoV-2-associated GBS who tested positive for SARS-CoV-2 RNA in the CSF. They developed symptoms of peripheral nerve damage 4-15 days after fever and confirmed SARS-CoV-2 infection, all of whom presented with progressive weakness of both lower limbs; three with autonomic nerve function impairment such as constipation and urination disorder; and one with polycranial neuritis and Miller-Fisher syndrome. Three patients were tested for anti-ganglioside antibodies, and one tested positive for GD1a-IgG. Four patients recovered well after treatment with anti-viral drugs combined with intravenous immunoglobulin. The present results showed that SARS-CoV-2 RNA can be detected via mNGS in the CSF of some patients with SARS-CoV-2-associated GBS, suggesting that SARS-CoV-2-associated GBS may have multiple pathogeneses.

Disability evaluation in patients with Guillain-Barre syndrome and SARS-CoV-2 infection

Objective

Several cases of Guillain-Barre syndrome (GBS) associated with SARS-CoV-2 infection have been described. This study illustrated the demographic, clinical, and neurophysiological characteristics of patients with GBS and COVID-19, as well as associated factors with disability at discharge.

Materials and methods

A retrospective analytical observational study was conducted. It included patients diagnosed with GBS admitted in a national reference center in Peru between 2019 and 2021. Epidemiological, clinical, neurophysiological, and cerebrospinal fluid data were analyzed. A multivariate analysis, using the generalized linear model, was performed, considering the presence of disability at discharge as the dependent variable.

Results

Eight-one subjects diagnosed with GBS were included. The mean age was 46.8 years (SD: 15.2), with a predominance of males (61.73%). The most frequent clinical presentation was the classic sensory-motor form in 74 cases (91.36%) with AIDP (82.35%) as the most frequent neurophysiological pattern in the group with COVID-19, while AMAN pattern predominated (59.26%) in those without COVID-19 (p = <0.000). The disability prevalence ratio at discharge between subjects with COVID-19 and those without COVID-19 was 1.89 (CI 1.06-3.34), p = 0.030, adjusted for age, sex, and neurophysiological subtype.

Conclusion

The neurophysiologic subtype AIDP, and a higher disability were associated with the presence of COVID-19.

Guillain-Barre Syndrome Followed by Covid-19 Infection, Vaccination and Other Precipitating Factors during the Pandemic

Background and Aims

Guillain-Barré syndrome (GBS) is usually triggered by an infection. Vaccination is mentioned as a possible trigger in a small number of GBS cases. The aim of this study was to notice GBS distinctness provoked by various triggers during the COVID-19 pandemic.

Material and Methods

A total of 109 GBS patients were divided into three groups, respectively: COVID-19 infection associated (19 patients), COVID-19 vaccination associated (16 patients) and precipitated by some other factors (74 patients). We compared the clinical, neurophysiological and laboratory characteristics of these three groups.

Results

Neither were differences recorded in the age of the patients of these three groups at the time of illness, nor in the number of days from the precipitating factor to the onset of symptoms. There were no clinical differences between groups related to severity of the disease or patients' recovery. The only clinical difference was observed in relation to facial nerve bilateral affection because it was significantly higher in the post-vaccination group. According to neurophysiological findings, demyelinating form dominated in all three groups.

Conclusion

Clinical characteristics, electrophysiological findings and laboratory characteristics did not differ significantly in Guillain-Barre syndrome followed by COVID-19 infection, vaccination and other precipitating factors during the pandemic. The bilateral involvement of facial nerves was significantly higher in the post-vaccination group. Most of these cases had a mild form of the disorder-distal paresthesias GBS variant.

Efficacy of intravenous immunoglobulin (IVIg) on COVID-19-related neurological disorders over the last 2 years: an up-to-date narrative review

Introduction

Among the clinical manifestations of SARS-CoV-2 infection, neurological features have been commonly reported and the state-of-the-art technique suggests several mechanisms of action providing a pathophysiological rationale for central and peripheral neurological system involvement. However, during the 1st months of the pandemic, clinicians were challenged to find the best therapeutic options to treat COVID-19-related neurological conditions.

Methods

We explored the indexed medical literature in order to answer the question of whether IVIg could be included as a valid weapon in the therapeutic arsenal against COVID-19-induced neurological disorders.

Results

Virtually, all reviewed studies were in agreement of detecting an acceptable to great efficacy upon IVIg employment in neurological diseases, with no or mild adverse effects. In the first part of this narrative review, the interaction of SARS-CoV-2 with the nervous system has been discussed and the IVIg mechanisms of action were reviewed. In the second part, we collected scientific literature data over the last 2 years to discuss the use of IVIg therapy in different neuro-COVID conditions, thus providing a summary of the treatment strategies and key findings.

Discussion

Intravenous immunoglobulin (IVIg) therapy is a versatile tool with multiple molecular targets and mechanisms of action that might respond to some of the suggested effects of infection through inflammatory and autoimmune responses. As such, IVIg therapy has been used in several COVID-19-related neurological diseases, including polyneuropathies, encephalitis, and status epilepticus, and results have often shown improvement of symptoms, thus suggesting IVIg treatment to be safe and effective.

Is there a causal nexus between COVID-19 infection, COVID-19 vaccination, and Guillain-Barré syndrome?

Guillain-Barré syndrome (GBS) is an immune-mediated inflammatory polyradiculoneuropathy, which commonly leads to a very high level of neurological disability. Especially, after the global outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the causation between GBS and SARS-CoV-2 infection and the coronavirus disease 2019 (COVID-19) vaccination have aroused widespread concern. In the review, we analyzed the impacts of SARS-CoV-2 infection and COVID-19 vaccination on GBS globally, aiming to further understand the characteristics of GBS associated with COVID-19. Based on the electrophysiological data, patients suffering from GBS related to COVID-19 manifested as an acute inflammatory demyelinating polyneuropathy (AIDP). Moreover, we summarized the current findings, which may evidence GBS linking to SARS-CoV-2 infection and COVID-19 vaccination, and discussed the underlying mechanisms whether and how the SARS-CoV-2 virus and COVID-19 vaccination can induce GBS and its variants.

Immunological, Clinical, and Epidemiological Features of Guillain-Barré Syndrome Associated with SARS-CoV-2 Infection

Objectives. There is a growing interest in understanding the association between Guillain-Barré syndrome (GBS) and SARS-CoV-2 infection. The aim of this study was to analyse various characteristics of GBS before and after the pandemic outbreak and thus identify possible distinctive features of GBS associated with SARS-CoV-2 (GBS-S). Material and Methods. In our centre, we retrospectively reviewed the records of patients diagnosed with GBS between January 2018 and March 2022. Epidemiological, clinical, and immunological data were analysed and compared between patients with GBS according to the time of diagnosis and antecedent events. Results. Thirty-nine patients with GBS were included: nine (23.1%) were diagnosed with GBS-S. GBS-S was most frequent in 2020 (6/13, 46.1%). Most of these patients developed a postinfectious classic demyelinating variant (4/9, 44.4%) with frequent bilateral facial paralysis (4/9, 44.4%). Serum antiganglioside antibodies (AGAs) were found in 1/9 patients with GBS-S. Serum anti-SSA/Ro60 antibodies were highly prevalent in GBS-S (7/9 (77.8%) vs. 3/11 (27.3%), $p=0.019$ ). Three cases associated with SARS-CoV-2 vaccination (GBS-V) were detected. Of note, two had bilateral facial paralysis and anti-SSA/Ro60 antibodies. Conclusion. Our findings suggest that SARS-CoV-2 has become an important antecedent event associated with GBS in our setting. GBS-S shows a postinfectious demyelinating immune-mediated profile with negative serological testing for AGAs. Serum anti-SSA/Ro60 antibodies were found frequently in these patients. Bilateral facial paralysis stands out as a possible characteristic clinical feature both in GBS-S and GBS-V. Larger, prospective studies are needed for a better understanding of its immunopathogenesis.

Spontaneous intramedullary hematoma following COVID-19 vaccination: A case report

A 67-year-old female was hospitalized due to right-sided hemiparesis and neck pain with rapid deterioration to a deep coma. She had received the Sinopharm vaccine 2 days earlier. MRI showed extensive cervicothoracic hematomyelia. She received intensive medical care for 2 months and was discharged. An 18-month follow-up showed significant neurological recovery.

Facial palsy as a manifestation of COVID-19: A systematic review of cases

Background and Aims

Facial palsy is a rare complication of the COVID-19 infection. Herein, we conducted a systematic review of all published cases of facial palsy post-COVID-19 infection in an attempt to educate the general population and medical practitioners regarding the likely occurrence of facial palsy in COVID-19 patients, its detection, effective treatment plan, and prognosis of the condition.

Methods

We searched PubMed, Google Scholar, and Directory of Open Access Journals (DOAJ) from December 1, 2019 to September 21, 2021.

Results

We included 49 studies bearing accounts of 75 cases who had facial palsy. The mean age of patients was 42.9 ± 19.59 years, with a male-to-female ratio of 8:7. The majority of the cases were reported from Brazil (n = 14), USA (n = 9), Turkey (n = 9), and Spain (n = 9). Noticeably, 30.14% of COVID-19 patients were diagnosed with Guillain-Barré syndrome. In total, 22.97% of patients complained of bilateral facial paralysis (n = 17), whereas ipsilateral paralysis was observed in 77.03% (n = 57). These were common complaints of Lagophthalmos, otalgia, facial drooping, dysarthria, and compromised forehead wrinkling. The treatment regimen mainly included the use of corticosteroids (n = 51) (69.86%), antivirals (n = 23) (31.51%), IVIG (n = 18) (24.66%), antibiotics (n = 13) (17.81%), antiretroviral (n = 9) (12.33%), and antimalarial (n = 8) (10.96%) medications. In all, 35.62% of patients (n = 26) adhered to a combination of antiviral and corticosteroid-based therapy. Positive treatment outcomes were observed in 83.58% (n = 56) of cases. In contrast, 10 patients (14.93%) showed nonsignificant recovery, out of which 3 (4.48%) died from the disease.

Conclusion

The association of facial palsy with COVID-19 is controversial and therefore requires further investigation and published work to confirm a causal relationship. However, physicians should not overlook the likelihood of facial palsy post-COVID-19 infection and treat it accordingly.

The Clinical Neurophysiology of COVID-19- Direct Infection, Long-Term Sequelae and Para-Immunization responses: A literature review

The COVID-19 pandemic resulting from the SARS-CoV-2 virus is in its third year. There is continuously evolving information regarding its pathophysiology and its effects on the nervous system. Clinical neurophysiology techniques are commonly employed to assess for neuroanatomical localization and/or defining the spectrum of neurological illness. There is an evolving body of literature delineating the effects of the SARS-CoV-2 virus on the nervous system as well as para-immunization responses to vaccination against this virus. This review focuses on the use of neurophysiological diagnostic modalities in the evaluation of potential acute and long-term neurological complications in patients that experience direct infection with SARS-CoV-2 and analyzes those reports of para-immunization responses to vaccination against the SARS-CoV-2 virus. The neurophysiological modalities to be discussed include electroencephalography (EEG), evoked potentials (EPs), nerve conduction studies and electromyography (EMG/NCV), autonomic function tests, transcranial magnetic stimulation (TMS) and Transcranial Doppler ultrasound (TCD).

Guillain-Barré syndrome following COVID-19 vaccine: A case report

Coronavirus disease is a viral infection affecting different organs with various morbidities and mortality. Vaccines are used to control the disease. COVID-19 vaccines have brought many benefits but their adverse effects should not be ignored. Here, we report a case of Guillain-Barré Syndrome Following Sinopharm COVID-19 Vaccine.

A bibliometric analysis of COVID-19 publications in neurology by using the visual mapping method

Background

The characteristic symptom of coronavirus disease 2019 (COVID-19) is respiratory distress, but neurological symptoms are the most frequent extra-pulmonary symptoms. This study aims to explore the current status and hot topics of neurology-related research on COVID-19 using bibliometric analysis.

Methods

Publications regarding neurology and COVID-19 were retrieved from the Web of Science Core Collection (WoSCC) on March 28 2022. The Advanced search was conducted using “TS = (‘COVID 19’ or ‘Novel Coronavirus 2019’ or ‘Coronavirus disease 2019’ or ‘2019-nCOV’ or ‘SARS-CoV-2’ or ‘coronavirus-2’) and TS = (‘neurology’or ‘neurological’ or ‘nervous system’ or ‘neurodegenerative disease’ or ‘brain’ or ‘cerebra’ or ‘nerve’)”. Microsoft Excel 2010 and VOSviewer were used to characterize the largest contributors, including the authors, journals, institutions, and countries. The hot topics and knowledge network were analyzed by CiteSpace and VOSviewer.

Results

A total of 5,329 publications between 2020 and 2022 were retrieved. The United States, Italy, and the United Kingdom were three key contributors to this field. Harvard Medical School, the Tehran University of Medical Sciences, and the UCL Queen Square Institute of Neurology were the major institutions with the largest publications. Josef Finsterer from the University of São Paulo (Austria) was the most prolific author. Tom Solomon from the University of Liverpool (UK) was the most cited author. Neurological Sciences and Frontiers in Neurology were the first two most productive journals, while Journal of Neurology held the first in terms of total citations and citations per publication. Cerebrovascular diseases, neurodegenerative diseases, encephalitis and encephalopathy, neuroimmune complications, neurological presentation in children, long COVID and mental health, and telemedicine were the central topics regarding the neurology-related research on COVID-19.

Conclusion

Neurology-related research on COVID-19 has attracted considerable attention worldwide. Research topics shifted from “morality, autopsy, and telemedicine” in 2020 to various COVID-19-related neurological symptoms in 2021, such as “stroke,” “Alzheimer's disease,” “Parkinson's disease,” “Guillain–Barre syndrome,” “multiple sclerosis,” “seizures in children,” and “long COVID.” “Applications of telemedicine in neurology during COVID-19 pandemic,” “COVID-19-related neurological complications and mechanism,” and “long COVID” require further study.

Guillain-Barré Syndrome and COVID-19: a one-year observational multicenter study

Background and purpose

Many single cases and small series of Guillain–Barré syndrome (GBS) associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection were reported during the coronavirus disease 19 (COVID‐19) outbreak worldwide. However, the debate regarding the possible role of infection in causing GBS is still ongoing. This multicenter study aimed to evaluate epidemiological and clinical findings of GBS diagnosed during the COVID‐19 pandemic in northeastern Italy in order to further investigate the possible association between GBS and COVID‐19.

Methods

Guillain–Barré syndrome cases diagnosed in 14 referral hospitals from northern Italy between March 2020 and March 2021 were collected and divided into COVID‐19‐positive and COVID‐19‐negative. As a control population, GBS patients diagnosed in the same hospitals from January 2019 to February 2020 were considered.

Results

The estimated incidence of GBS in 2020 was 1.41 cases per 100,000 persons/year (95% confidence interval 1.18–1.68) versus 0.89 cases per 100,000 persons/year (95% confidence interval 0.71–1.11) in 2019. The cumulative incidence of GBS increased by 59% in the period March 2020–March 2021 and, most importantly, COVID‐19‐positive GBS patients represented about 50% of the total GBS cases with most of them occurring during the two first pandemic waves in spring and autumn 2020. COVID‐19‐negative GBS cases from March 2020 to March 2021 declined by 22% compared to February 2019–February 2020.

Conclusions

Other than showing an increase of GBS in northern Italy in the “COVID‐19 era” compared to the previous year, this study emphasizes how GBS cases related to COVID‐19 represent a significant part of the total, thus suggesting a relation between COVID‐19 and GBS.

Dysautonomia in COVID-19 Patients: A Narrative Review on Clinical Course, Diagnostic and Therapeutic Strategies

Introduction

On March 11, 2020, the World Health Organization sounded the COVID-19 pandemic alarm. While efforts in the first few months focused on reducing the mortality of infected patients, there is increasing data on the effects of long-term infection (Post-COVID-19 condition). Among the different symptoms described after acute infection, those derived from autonomic dysfunction are especially frequent and limiting.

Objective

To conduct a narrative review synthesizing current evidence of the signs and symptoms of dysautonomia in patients diagnosed with COVID-19, together with a compilation of available treatment guidelines.

Results

Autonomic dysfunction associated with SARS-CoV-2 infection occurs at different temporal stages. Some of the proposed pathophysiological mechanisms include direct tissue damage, immune dysregulation, hormonal disturbances, elevated cytokine levels, and persistent low-grade infection. Acute autonomic dysfunction has a direct impact on the mortality risk, given its repercussions on the respiratory, cardiovascular, and neurological systems. Iatrogenic autonomic dysfunction is a side effect caused by the drugs used and/or admission to the intensive care unit. Finally, late dysautonomia occurs in 2.5% of patients with Post-COVID-19 condition. While orthostatic hypotension and neurally-mediated syncope should be considered, postural orthostatic tachycardia syndrome (POTS) appears to be the most common autonomic phenotype among these patients. A review of diagnostic and treatment guidelines focused on each type of dysautonomic condition was done.

Conclusion

Symptoms deriving from autonomic dysfunction involvement are common in those affected by COVID-19. These symptoms have a great impact on the quality of life both in the short and medium to long term. A better understanding of the pathophysiological mechanisms of Post-COVID manifestations that affect the autonomic nervous system, and targeted therapeutic management could help reduce the sequelae of COVID-19, especially if we act in the earliest phases of the disease.

Acute motor and sensory axonal neuropathy (AMSAN) associated with COVİD-19 infection ; a case report

Myalgia and headache are relatively common in COVID-19 disease, but the serious neurological disease is rare. In this case, we describe the symptoms and clinic of AMSAN, a rare variant of Guillain-Barre syndrome (GBS) due to COVID 19. We presented a case of AMSAN, a rare variant of GBS, in a 46-year-old male patient with a poor overall condition that did not recover after COVID-19 disease, loss of strength in all four extremities, and CSF and EMG findings. We added another GBS case due to Covid-19 infection to the literature. It should always be kept in mind that GBS may develop after the COVID-19 disease.

Possible association between Guillain‑Barré syndrome and SARS‑CoV‑2 infection in children: A case report and literature review

Neurological manifestations of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been reported in adults and in children, varying from mild to more debilitant symptoms, including fatigue, headache and dizziness. A series of studies have revealed a possible association between Guillain-Barré syndrome (GBS), the most common cause of acute flaccid paralysis at all ages, and SARS-CoV-2 infection. Case reports of novel coronavirus disease 2019 (COVID-19)-associated GBS mainly include adult patients, while only a few pediatric cases have been reported. The present study describes a case of GBS in an Italian 9-year-old girl with previous SARS-CoV-2 infection as a possible trigger, and also conducts a literature review on pediatric COVID-19-associated GBS cases.

Is there a difference between GBS triggered by COVID-19 and those of other origins?

Background

Since the outbreak of the coronavirus disease 2019 (COVID-19), an increasing number of Guillain–Barré syndrome (GBS) cases following the infection has been reported. The aim of our study was to detect patients with GBS treated in our hospital over a 1-year period and to compare the characteristics and outcomes of those triggered by COVID-19 with the rest of GBS patients. Our prospective study included 29 patients who were diagnosed with GBS from March 2020 to March 2021. Based on the preceding event, patients were stratified as post-COVID-19 and non-COVID-19. The GBS disability scale (GDS) was used to assess functional disability.

Results

We identified 10 (34.5%) patients with post-COVID-19 GBS and 19 (65.5%) patients with non-COVID-19 GBS. The median time from the preceding event to the symptoms onset was longer in post-COVID-19 than in non-COVID-19 GBS patients (p = 0.04). However, the time from the symptom onset to the nadir did not differ (p = 0.12). GDS at admission, as well as at nadir, did not differ between these two groups. The level of proteinorrachia was higher in post-COVID-19 GBS patients (p = 0.035). The most frequent subtype of GBS in both groups was acute inflammatory demyelinating polyneuropathy (AIDP). GDS score at discharge (p = 0.56) did not differ between two study groups.

Conclusions

There was no difference in clinical and electrophysiological features, disease course, and outcome in post-COVID-19 compared with non-COVID-19 GBS patients.

The Pathophysiology of Long COVID throughout the Renin-Angiotensin System

COVID-19 has expanded across the world since its discovery in Wuhan (China) and has had a significant impact on people's lives and health. Long COVID is a term coined by the World Health Organization (WHO) to describe a variety of persistent symptoms after acute SARS-CoV-2 infection. Long COVID has been demonstrated to affect various SARS-CoV-2-infected persons, independently of the acute disease severity. The symptoms of long COVID, like acute COVID-19, consist in the set of damage to various organs and systems such as the respiratory, cardiovascular, neurological, endocrine, urinary, and immune systems. Fatigue, dyspnea, cardiac abnormalities, cognitive and attention impairments, sleep disturbances, post-traumatic stress disorder, muscle pain, concentration problems, and headache were all reported as symptoms of long COVID. At the molecular level, the renin-angiotensin system (RAS) is heavily involved in the pathogenesis of this illness, much as it is in the acute phase of the viral infection. In this review, we summarize the impact of long COVID on several organs and tissues, with a special focus on the significance of the RAS in the disease pathogenesis. Long COVID risk factors and potential therapy approaches are also explored.

Demographic, clinical, investigational characteristics of COVID-19 related Guillain-Barré syndrome with differences from typical and another virus-related Guillain-Barré syndrome

BACKGROUNDS

SARS-CoV-2 infection typically presents with fever and respiratory symptoms. Besides this, COVID-19 related central and peripheral nervous system manifestations are emerging.

OBJECTIVES

This study summarises the demographics, clinical profile, laboratory findings, management strategies, and outcomes in a large number of patients with COVID-19 related GBS and its variants. We also compared its clinical profile with Zika and dengue virus-related GBS.

METHODS

Authors carried out a literature search up to Dec 31, 2020, in MEDLINE, PubMed, SCOPUS, Cochrane database, and Google Scholar for all published articles.

RESULTS

The study identified 54 different types of articles consisting of 70 cases from 17 countries worldwide. Maximum cases 15 (21.4%) were identified from Italy, followed by USA 12 (17.1%), Spain 11 (15.7%), and Iran 10 (14.3%). The age group more than 60 years had most cases with 32 (45.7%) cases followed by age group 40-60 with cases 25 (35.7%) with male and female ratio 2. Maximum cases were treated with IVIG infusion 58 (82.9%), followed by Plasma exchange 13 (18.6%) cases. Out of 70 cases, 7 (10%) cases were manifested as Miller-Fisher syndrome. The most predominant electrodiagnostic variant was demyelinating neuropathy in 41 (73.21%) cases. The outcome reported in 67 cases was survival in 63 (90%) cases and the death of 4 (5.7%) cases.

CONCLUSION

Covid 19 related GBS were reported worldwide with a better outcome. Both postinfectious or parainfectious patterns were reported. Early recognition with prompt management of GBS can prevent further severe morbidity and mortality.

Acute neuromuscular syndromes with respiratory failure during COVID-19 pandemic: where we stand and challenges ahead

Coronavirus disease 2019 (COVID-19), a disease caused by the novel betacoronavirus SARS-COV-2, has become a global pandemic threat. SARS- COV-2 is structurally similar to SARS-COV, and both bind to the angiotensin-converting enzyme 2 (ACE2) receptor to enter human cells. While patients typically present with fever, shortness of breath, sore throat, and cough, in some cases neurologic manifestations occur due to both direct and indirect involvement of the nervous system. Case reports include anosmia, ageusia, central respiratory failure, stroke, acute necrotizing hemorrhagic encephalopathy, toxic-metabolic encephalopathy, headache, myalgia, myelitis, ataxia, and various neuropsychiatric manifestations. Some patients with COVID-19 may present with concurrent acute neuromuscular syndromes such as myasthenic crisis (MC), Guillain–Barré syndrome (GBS) and idiopathic inflammatory myopathies (IIM); these conditions coupled with respiratory failure could trigger a life-threatening condition. Here, we review the current state of knowledge on acute neuromuscular syndromes with respiratory failure related to COVID-19 infection in an attempt to clarify and to manage the muscle dysfunction overlapping SARS-COV-2 infection.

The potential association between COVID-19 disease and Guillain-Barré syndrome

The aim is to investigate the rate of GBS in the pre- and postpandemic period and potential differences in probable COVID-19-associated Guillain-Barré syndrome (GBS) cases and nonassociated cases. The medical records of individuals older than 18 years who were hospitalized with acute and rapidly developing progressive extremity weakness between March 2019 and March 2021 were analyzed retrospectively, and the rate of GBS 1 year before the first reported COVID-19 case (March 2020) in Turkey and 1 year later was compared. Neurological symptoms, medical histories, and GBS disability scores, as well as the findings of electrophysiological, blood, and cerebrospinal fluid (CSF) investigations at the time of presentation, were reviewed. The GBS cases were divided into those with confirmed COVID-19 within 6 weeks before the clinical presentation of GBS and those without COVID-19. The rate of COVID-19 was significantly higher in the patients with GBS as an etiological factor. When the probable COVID-19-associated GBS cases and nonassociated cases were compared, there was a significant between-group difference with respect to sedimentation, C-reactive protein, D-dimer, ferritin, albumin, lymphocyte number, mean platelet volume, neutrophil-lymphocyte ratio, fibrinogen, and lactate dehydrogenase values. In addition, there was a significant between-group difference in admission and discharge disability scores. The GBS rate did not increase after the COVID-19 pandemic, but probable COVID-19-associated GBS significantly affected inflammatory markers and admission-discharge GBS disability scores.

[COVID-19-associated Guillain-Barré syndrome in infectious period: a case report]

A 75-year-old man with a history of hypertension developed weakness and sensory disturbance in the extremities 1 week after upper respiratory tract infection and faced difficulty walking. Screening at the time of hospital admission revealed an incidental positive SARS-CoV-2 PCR test, and COVID-19 was diagnosed. Neurological findings showed dysarthria, dysphagia, absence of deep tendon reflexes in the extremities, distal-dominant muscle weakness, sensory disturbance, urinary retention and constipation. Nerve conduction studies showed prolonged distal latency, decreased conduction velocity, and poor F-wave response, leading to a diagnosis of COVID-19-associated Guillain-Barré syndrome (GBS). The patient was treated with intravenous immunoglobulin, and his neurological symptoms improved without the need of a ventilator. Anti-ganglioside autoantibodies were negative. The patient developed GBS during the infectious period of SARS-CoV-2 and was treated in the isolation ward by clinical staff with personal protective equipment. Because COVID-19-associated GBS can develop during the infectious period of SARS-CoV-2, it is important for neurologists to consider GBS and other neurological disorders as being potentially COVID-19-related, and to treat patients with COVID-19 accordingly.

Neurographic Evidence of Inflammatory Polyneuropathies in Peri-COVID-19 Circumstances and Their Relationship With Acute Disease Severity and Inflammatory Storm

Recently, there has been increasing evidence among people infected with coronavirus disease 2019 (COVID-19) of being diagnosed with the typical acute post-infectious inflammatory polyneuroradiculopathy that was formerly known as Guillain-Barré syndrome (GBS), and it is not uncommon that some of them develop chronic inflammatory demyelinating polyneuroradiculopathy (CIDP). However, there is still a large debate and controversy about the link between COVID-19 and polyneuropathy. As a result, a multicentric retrospective cohort study was conducted in Basrah Governorate in the south of Iraq that included 2240 patients over a period of six months. Of those, 1344 patients had a history of COVID-19 in the previous year, and 1.14% of them developed inflammatory polyneuropathy, while only 0.29% (896 patients) of those with no history of COVID-19 had developed inflammatory polyneuropathy. This difference is highly significant, with a relative risk equal to six. The majority of the inflammatory polyneuropathy (44.4%) was diagnosed four to 12 weeks after the COVID-19 infection, with GBS being the most common type (72.2% of cases). Moreover, the nerve conduction velocity, the distal latency, and the amplitude of the most studied nerves were slower, more prolonged, and lower, respectively, among the COVID-19 groups compared with the non-COVID-19 group. Furthermore, there is an inverse correlation between the nerve conduction velocity in the majority of studied nerves and certain inflammatory biomarkers, such as serum ferritin, interleukin-6, and c-reactive protein. Although the occurrence of inflammatory polyneuropathy is more common among the less severe groups of COVID-19, if it occurs in the severe groups, it shows a more aggressive presentation.

Hot Topics on COVID-19 and Its Possible Association with Guillain-Barré Syndrome

As the COVID-19 pandemic progresses, reports of neurological manifestations are increasing. However, despite a high number of case reports and case series on COVID-19 and Guillain-Barré-Syndrome (GBS), a causal association is still highly debated, due to the lack of case-control studies. In this opinion paper, we focus on a few clinically relevant questions regarding the possible link between GBS and SARS-CoV-2 infection or vaccination based on our personal clinical experience and literature review.

Guillain-Barré syndrome associated with Coronavirus disease 2019: A case from Nepal

Coronavirus disease 2019 (COVID-19) has now spread widely after the outbreak since December 31, 2019. Guillain-Barré syndrome is an immunological postinfectious neuropathy, which has been reported to be a rare but possible complication COVID-19. We report a case of Guillain-Barré syndrome associated with COVID-19 in Nepal.

Consider differentials before diagnosing COVID-19 associated polyradiculitis

Evidence is accumulating that SARS-CoV-2 infections and SARS-CoV-2 vaccinations can induce Guillain-Barre syndrome (GBS). More than 400 GBS cases after SARS-CoV-2 infection respectively vaccination have been reported as per the end of 2021. GBS is usually diagnosed according to the Brighton criteria, but also the Besta criteria or Hadden criteria are applied. The diagnosis can be supported by MRI with contrast medium of the cranial or spinal nerves showing enhancing nerve roots. As GBS can be complicated by autonomic dysfunction such as pupillary abnormalities, salivatory dysfunction, reduced heart rate variability, bowel disturbance (constipation, diarrhea), urinary hesitancy, urinary retention, or impotence, it is crucial to investigate GBS patients for autonomic involvement. Before diagnosing GBS various differentials need to be excluded, including neuropathy as a side effect of the anti-SARS-CoV-2 medication, critical ill neuropathy in COVID-19 patients treated on the ICU, and compression neuropathy in COVID-19 patients requiring long-term ventilation.

Vaccination in pediatric acquired inflammatory immune-mediated neuromuscular disorders

AIM

To analyse literature data on vaccine related induction, worsening of the disease and disease reccurrences as well as vaccine safety and efficacy among pediatric patients with acquired inflammatory immune-mediated neuromuscular disorders (NMD).

METHODS

Medline, Pub Med and Scopus database search from 1975 to 2020 focused on pediatric age was conducted including peer reviews, meta analyses and epidemiological studies on vaccination and Guillain-Barré syndrome (GBS), Bell's palsy, optic neuritis (ON), myasthenia gravis (MG), chronic inflammatory demyelinating polyneuropathy (CIDP) and immune-mediated inflammatory myopathy (IM).

RESULTS AND CONCLUSION

s: There are no strong evidence supporting relationship between vaccination with different pediatric vaccines and development of first episodes or reccurrences of GBS, Bell's palsy, optic neuritis (ON), juvenile MG, CIDP, and IM. The vaccination and revaccination with inactivated vaccines is considered safe in children with medical history of GBS, Bell's palsy, ON, MG and IM. Caution when immunization against influenza, quadrivalent conjugated meningococcal vaccine (MCV4) and pneumococcal disease and avoiding tetanus toxoid immunization in CIDP patients is suggested. Patients with immune mediated acquired NMD should be vaccinated with live vaccines before the initiation of immunosupressive treatment. Immunosuppressed patients with low protective antibody titers should be considered for revaccination.

Guillain-Barré Syndrome in the COVID-19 Pandemic

There have been several reported cases of severe acute respiratory syndrome (SARS-CoV-2) infection that were associated with an increased incidence of neurological manifestations, including Guillain–Barré syndrome (GBS). This review aims to present information on the reports of GBS associated with coronavirus disease 2019 (COVID-19) infection. Our review is retrospective work examining articles published from the 1 April 2020 to the 8 May 2021 in the English language. We used the diagnostic criteria and classification published by the National Institute of Neurological Disorders and Stroke and Brighton Collaboration. GBS is usually a postinfectious syndrome, but GBS in the COVID-19 pandemic also takes on a para-infectious profile. In the reports, the genetic factor has a role in developing GBS in some patients. In conclusion, the association between COVID-19 and GBS is not very clear. Still, one mechanism is strongly associated with COVID-19 and immune-mediated neurological complications, which is molecular mimicry between SARS-CoV-2 and human autoantigens.

Neurologic Complications in Adult and Pediatric Patients with SARS-CoV-2 Infection

SARS-CoV-2 has an impact on the nervous system as a result of pathological cellular and molecular events at the level of vascular and neural tissue. Severe neurologic manifestations including stroke, ataxia, seizure, and depressed level of consciousness are prevalent in patients with SARS-CoV-2 infection. Although the mechanism is still unclear, SARS-CoV-2 has been associated with the pathogenesis of intravascular coagulation and angiotensin-converting enzyme-I, both exacerbating systemic inflammation and contributing to hypercoagulation or blood–brain barrier leakage, resulting in ischemic or hemorrhagic stroke. On the other hand, the SARS-CoV-2 spike protein in neural tissue and within the cerebrospinal fluid may induce neural dysfunction, resulting in neuroinflammation, which is exacerbated by peripheral and neural hypercytokinemia that can lead to neuronal damage and subsequent neuroinflammation. A deeper understanding of the fundamental biological mechanisms of neurologic manifestations in SARS-CoV-2 infection can pave the way to identifying a single biomarker or network of biomarkers to help target neuroprotective therapy in patients at risk for developing neurological complications.

Survivors of COVID-19 exhibit altered amplitudes of low frequency fluctuation in the brain: a resting-state functional magnetic resonance imaging study at 1-year follow-up

Although some short-term follow-up studies have found that individuals recovering from coronavirus disease 2019 (COVID-19) exhibit anxiety, depression, and altered brain microstructure, their long-term physical problems, neuropsychiatric sequelae, and changes in brain function remain unknown. This observational cohort study collected 1-year follow-up data from 22 patients who had been hospitalized with COVID-19 (8 males and 11 females, aged 54.2 ± 8.7 years). Fatigue and myalgia were persistent symptoms at the 1-year follow-up. The resting state functional magnetic resonance imaging revealed that compared with 29 healthy controls (7 males and 18 females, aged 50.5 ± 11.6 years), COVID-19 survivors had greatly increased amplitude of low-frequency fluctuation (ALFF) values in the left precentral gyrus, middle frontal gyrus, inferior frontal gyrus of operculum, inferior frontal gyrus of triangle, insula, hippocampus, parahippocampal gyrus, fusiform gyrus, postcentral gyrus, inferior parietal angular gyrus, supramarginal gyrus, angular gyrus, thalamus, middle temporal gyrus, inferior temporal gyrus, caudate, and putamen. ALFF values in the left caudate of the COVID-19 survivors were positively correlated with their Athens Insomnia Scale scores, and those in the left precentral gyrus were positively correlated with neutrophil count during hospitalization. The long-term follow-up results suggest that the ALFF in brain regions related to mood and sleep regulation were altered in COVID-19 survivors. This can help us understand the neurobiological mechanisms of COVID-19-related neuropsychiatric sequelae. This study was approved by the Ethics Committee of the Second Xiangya Hospital of Central South University (approval No. 2020S004) on March 19, 2020.

COVID-19 Neuromuscular Involvement in Post-Acute Rehabilitation

Background: Coronavirus disease 2019 (COVID-19) is associated with muscle and nerve injuries as a consequence of prolonged critical illness or the infection itself. In this study, we evaluated neuromuscular involvement in patients who underwent post-acute intensive rehabilitation after COVID-19. Methods: Clinical and neurophysiological evaluations, including nerve conduction studies and electromyography, were performed on 21 consecutive patients admitted for rehabilitation after COVID-19. Results: Clinical signs suggesting muscle or nerve involvement (weakness, reduced deep tendon reflexes, impaired sensitivity, abnormal gait) were found in 19 patients. Neurophysiological examinations confirmed neuromuscular involvement in 17 patients: a likely association of critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) was found in 5 patients; CIM alone was found in 4 patients; axonal sensory-motor polyneuropathy was found in 4 patients (CIP in 2 patients, metabolic polyneuropathy in 2 patients); Guillain-Barré syndrome was found in 2 patients (classical demyelinating sensory-motor polyneuropathy and acute motor axonal neuropathy, respectively); peroneal nerve injury was found in 1 patient; and pre-existing L4 radiculopathy was found in 1 patient. Conclusions: Neuromuscular involvement is a very common finding among patients admitted for rehabilitation after COVID-19, and proper investigation should be conducted when muscle or nerve injury is suspected for adequate rehabilitative strategy planning.

Emerging Infection, Vaccination, and Guillain-Barré Syndrome: A Review

Guillain-Barré syndrome (GBS) is an autoimmune disorder of the peripheral nervous system that typically develops within 4 weeks after infection. In addition to conventional infectious diseases with which we are familiar, emerging infectious diseases, such as Zika virus infection and coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have also been suggested to be associated with GBS. GBS is mainly categorized into a demyelinating subtype known as acute inflammatory demyelinating polyneuropathy (AIDP) and an axonal subtype known as acute motor axonal neuropathy (AMAN). Most patients who develop GBS after Zika virus infection or COVID-19 have AIDP. The concept of molecular mimicry between pathogens and human peripheral nerve components was established through studies of AMAN with anti-ganglioside GM1 antibodies occurring after Campylobacter jejuni infection. Although such mimicry between specific pathogens and myelin or Schwann cell components has not been clearly demonstrated in AIDP, a similarity of Zika virus and SARS-CoV-2 proteins to human proteins has been suggested. With the development of global commerce and travel, emerging infectious diseases will continue to threaten public health. From this viewpoint, the development of vaccines and antiviral drugs is important to prepare for and control emerging infectious diseases. Although a decrease in the number of patients after the 2015-2016 Zika epidemic increased the difficulty in conducting phase 3 trials for Zika virus vaccines, the efficacy and safety of new vaccines have recently been demonstrated for COVID-19. In general, vaccines can decrease the risk of infectious disease by stimulating the immune system, and discussions regarding an increased risk of autoimmune disorders, such as GBS, have been ongoing for many years. However, the risk of GBS is not considered a legitimate reason to limit the administration of currently available vaccines, as only a trivial association or no association with GBS has been demonstrated.

Acute central and peripheral nervous system injury associated with coronavirus disease 2019: recognition and treatment strategies

PURPOSE OF REVIEW

Acute central and peripheral nervous system injury may occur in association with coronavirus disease 2019 (COVID-19) caused by infection with the severe acute respiratory syndrome coronavirus 2 virus. This review will assist readers to recognize neurologic manifestations associated with COVID-19 including common and life-threatening symptoms and diagnostic testing. We will also review current recommendations for treatment of neurologic injury associated with COVID-19 infection in children.

RECENT FINDINGS

Data from systematic reviews and prospectively collected cohorts of children with COVID-19 are beginning to characterize the breadth of neurologic manifestations associated with COVID-19 in the acute infectious and postinfectious periods. Among hospitalized children in particular, neurologic symptoms are common. Life threatening conditions including encephalitis, myelitis, stroke, and demyelinating syndromes have been reported. Within the pediatric population, age, and preexisting neurologic conditions appear to be important factors in determining likely phenotypes. Treatment at this time is based on careful neuromonitoring, supportive care, and neuromodulatory therapies as indicated.

SUMMARY

Neurologic symptoms are common in children with COVID-19 and may be life threatening. The pathophysiology, therapeutic options, and long-term outcomes from COVID-19 associated neurologic injury are currently being investigated.

Neurological Manifestations and Long-term Sequelae in Hospitalized Patients with COVID-19

Objective Various neurological manifestations have been increasingly reported in coronavirus disease 2019 (COVID-19). We determined the neurological features and long-term sequelae in hospitalized COVID-19 patients. Methods We retrospectively studied 95 consecutive hospitalized patients with COVID-19 between March 1 and May 13, 2020. Acute neurological presentations (within two weeks of the symptom onset of COVID-19) were compared between 60 non-severe and 35 severely infected patients who required high-flow oxygen. In the 12 ventilated patients (the most severe group), we evaluated neurological complications during admission, subacute neurological presentations, and neurological sequelae (51 and 137 days from the onset [median], respectively). Results Of the 95 patients (mean age 53 years old; 40% women), 63% had acute neurological presentations, with an increased prevalence in cases of severe infections (83% vs. 52%, p<0.001). Impaired consciousness and limb weakness were more frequent in severe patients than in non-severe ones (0% vs. 49%; p<0.001, and 0% vs. 54%; p<0.001, respectively). In the most severe group (mean age 72 years old; 42% women), 83% of patients had neurological complications [cerebrovascular disease (17%), encephalopathy (82%), and neuropathy (55%)], and 92% had subacute neurological presentations [impaired consciousness (17%), higher brain dysfunction (82%), limb weakness (75%), and tremor (58%)]. Neurological sequelae were found in 83% of cases, including higher brain dysfunction (73%), limb weakness (50%), and tremor (58%). Conclusions Neurological manifestations are common in COVID-19, with the possibility of long-lasting sequelae.

SARS-CoV-2-associated Guillain-Barré syndrome is a para-infectious disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been linked to the Guillain-Barré syndrome (GBS). The objective of the present study is to identify specific clinical features of cases of GBS reported in the literature associated with SARS-CoV-2 infection. We searched Pubmed, and included single case reports and case series with full text in English, reporting original data of patients with GBS and a confirmed recent SARS-CoV-2 infection. Clinical data were extracted. We identified 28 articles (22 single case reports and 6 case series), reporting on a total of 44 GBS patients with confirmed SARS-CoV-2 infection. SARS-CoV-2 infection was confirmed through serum reverse transcriptase-polymerase chain reaction in 72.7% of cases. A total of 40 patients (91%) had symptoms compatible with SARS-CoV-2 infection before the onset of the GBS. The median period between the onset of symptoms of SARS-CoV-2 infection and symptoms of the GBS was 11.2 days (range, 2-23). The most common clinical features were: leg weakness (61.4%), leg paresthesia (50%), arm weakness (50.4%), arm paresthesia (50.4%), hyporeflexia/areflexia (48%) and ataxia (22.7%). In total, 38.6% (n = 17) were found to have facial paralysis. Among 37 patients in whom nerve-conduction studies and electromyography were performed, of which 26 patients (59.1%) were consistent with the acute inflammatory demyelinating polyneuropathy subtype of the GBS. The present retrospective analysis support the role of the SARS-CoV-2 infection in the development of the GBS, may trigger GBS as para-infectious disease, and lead to SARS-CoV-2-associated GBS.

COVID-19 Infection: A Neuropsychiatric Perspective

As a potentially life-threatening disease with no definitive treatment and without fully implemented population-wide vaccination, COVID-19 has created unprecedented turmoil in socioeconomic life worldwide. In addition to physical signs from the respiratory and many other systems, the SARS-CoV-2 virus produces a broad range of neurological and neuropsychiatric problems, including olfactory and gustatory impairments, encephalopathy and delirium, stroke and neuromuscular complications, stress reactions, and psychoses. Moreover, the psychosocial impact of the pandemic and its indirect effects on neuropsychiatric health in noninfected individuals in the general public and among health care workers are similarly far-ranging. In addition to acute neuropsychiatric manifestations, COVID-19 may also produce late neuropsychiatric sequelae as a function of the psychoneuroimmunological cascade that it provokes. The present article presents a state-of-the-science review of these issues through an integrative review and synthesis of case series, large-cohort studies, and relevant meta-analyses. Heuristics for evaluation and further study of the neuropsychiatric manifestations of SARS-CoV-2 infection are offered.

COVID-19-Related Multifocal Demyelinating Neuropathy: Causation or Association

COVID-19 produces pulmonary symptoms in the majority of symptomatic patients. However, demyelinating illnesses of the central and peripheral nervous system are reported in few patients. We report a case of multifocal demyelination involving the peripheral nerves as well as the optic nerve who developed these symptoms while on corticosteroid therapy, which was being given for treating the COVID-19-related inflammatory state. He improved with a short course of steroids. This is the first reported case of multifocal demyelinating neuropathy in relation to COVID-19 to the best of our knowledge. Though there have been reports of COVID-19-associated central nervous system and peripheral nervous system demyelinating illness, whether COVID-19 is causative or just an association is yet to be discerned.

Guillain-​Barré Syndrome Associated with COVID-19 Vaccination

We conducted a multi-institutional study in Taiwan and a systematic review of the literature for reports of Guillain-​Barré syndrome after coronavirus disease vaccination. This condition, mostly the classic form and the acute inflammatory demyelinating polyneuropathy subtype, has been reported in 39 cases and has occurred within 2 weeks of vaccine administration.

Getting paralysed after COVID: Guillain-Barre syndrome

Neurological involvement after coronavirus disease (COVID-19) pneumonias is common and occurs in almost one-third of the patients. The commonest neurological symptoms are ageusia, anosmia, headache, nausea, vomiting, dizziness, and myalgia. Guillain-Barre syndrome (GBS) is a rare manifestation of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection; whereas the common neurological manifestations of the SARS-CoV-2 infection occur with the onset of the respiratory symptoms and may be due to the direct invasion of the nervous system by the virus, GBS in COVID-19 follows a time lag of 1-4 weeks and may be attributable to the immune mechanism of molecular mimicry. Here we report a case of GBS in a patient of COVID-19 which occurred on the 22^nd day after the onset of the disease. The patient recovered completely and went home walking.

Guillain-Barré syndrome after SARS-CoV-2 infection in an international prospective cohort study

In the wake of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, an increasing number of patients with neurological disorders, including Guillain-Barré syndrome (GBS), have been reported following this infection. It remains unclear, however, if these cases are coincidental or not, as most publications were case reports or small regional retrospective cohort studies. The International GBS Outcome Study is an ongoing prospective observational cohort study enrolling patients with GBS within 2 weeks from onset of weakness. Data from patients included in this study, between 30 January 2020 and 30 May 2020, were used to investigate clinical and laboratory signs of a preceding or concurrent SARS-CoV-2 infection and to describe the associated clinical phenotype and disease course. Patients were classified according to the SARS-CoV-2 case definitions of the European Centre for Disease Prevention and Control and laboratory recommendations of the World Health Organization. Forty-nine patients with GBS were included, of whom eight (16%) had a confirmed and three (6%) a probable SARS-CoV-2 infection. Nine of these 11 patients had no serological evidence of other recent preceding infections associated with GBS, whereas two had serological evidence of a recent Campylobacter jejuni infection. Patients with a confirmed or probable SARS-CoV-2 infection frequently had a sensorimotor variant 8/11 (73%) and facial palsy 7/11 (64%). The eight patients who underwent electrophysiological examination all had a demyelinating subtype, which was more prevalent than the other patients included in the same time window [14/30 (47%), P = 0.012] as well as historical region and age-matched control subjects included in the International GBS Outcome Study before the pandemic [23/44 (52%), P = 0.016]. The median time from the onset of infection to neurological symptoms was 16 days (interquartile range 12-22). Patients with SARS-CoV-2 infection shared uniform neurological features, similar to those previously described in other post-viral GBS patients. The frequency (22%) of a preceding SARS-CoV-2 infection in our study population was higher than estimates of the contemporaneous background prevalence of SARS-CoV-2, which may be a result of recruitment bias during the pandemic, but could also indicate that GBS may rarely follow a recent SARS-CoV-2 infection. Consistent with previous studies, we found no increase in patient recruitment during the pandemic for our ongoing International GBS Outcome Study compared to previous years, making a strong relationship of GBS with SARS-CoV-2 unlikely. A case-control study is required to determine if there is a causative link or not.