COVID-19-associated Guillain-Barre syndrome
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.
Synonyms and keywords:
Overview
The coronavirus (COVID-19) pandemic originated in Wuhan (China) on December 2019.Although respiratory complications are more common, neurological manifestations are also increasingly reported. Guillain-Barre syndrome is preceded by upper respiratory infection or gastrointestinal illness.Few cases of COVID-19 associated Guillain-Barre syndrome have been reported.
Historical Perspective
- COVID-19 (SARS-CoV-2) outbreak initiated in December, 2019 in Wuhan, Hubei Province, China.[1]
- In northern Italy five patients developed Guillain–Barré syndrome after the onset of coronavirus disease 2019 (Covid-19) from February 28 through March 21, 2020.[2]
- In June 2020,the very first case of COVID-19 associated GBS in the United States was reported.[3]
Classification
- There is no established system for the classification of COVID-19 associated Guillain-Barre Syndrome.
Pathophysiology
- Guillain–Barre syndrome causes immune-mediated damage to the peripheral nerves that usually follows gastrointestinal or respiratory illnesses. The polyneuropathy in Guillain–Barre syndrome is believed to be due to cross-immunity against epitopes of peripheral nerve components that it shares with the epitopes on the cell surface of bacteria that produces an antecedent infection [4]. Most common antecedent infections are Campylobacter jejuni ,Zika virus and influenza virus.
- The mechanism of Guillain–Barre syndrome in patients infected with COVID-19 is not fully understood yet.
- COVID-19 stimulates inflammatory cells and produces various inflammatory cytokines and as a result, it initiates immune-mediated processes[5][6].'Molecular mimicry' as a mechanism of autoimmune disorder plays an important role in formation of Guillain–Barre syndrome. It is not yet clear whether COVID-19 induces the production of antibodies against specific gangliosides that usually appear with certain forms of Guillain–Barre syndrome[6].
In the future further investigations should be conducted about the mechanism of GBS in patients with COVID-19 for better understanding.
Causes
- COVID-19 associated Guillain-Barre syndrome may be caused by SARS-CoV-2 virus.
Differentiating COVID-19-associated Guillain-Barre syndrome from other Diseases
- COVID-19 associated Guillain-Barre syndrome[4]
- It has been reported in Northern Italy,United States, Iran
- Affects mostly elderly people
- More males are affected than females
- Presence of Fever, cough, dyspnea, ageusia, hyposmia before the onset of GBS
- Takes 5-14 days to develop GBS
- Facial Diplegia common
- Dysautonomia less common
- Outcome is poor, residual weakness, dysphagia, long ICU stay
- Differentiating from Typical Guillain-Barre syndrome:[4]
- Typical Guillain-Barre syndrome occurs worldwide
- Affects all age groups,
- Male 1.5 times more affected than females,
- Presence of preceeding respiratory/gastrointestinal illness
- Takes less than 6 weeks to develop GBS from initial illness
- Facial Diplegia common
- Dysautonomia common
- Prognosis is good, persistent disability in 20%-30% cases
- Differentiating from Zika virus-related Guillain-Barre syndrome:[4]
- Zika virus-related Guillain-Barre syndrome was reported in Latin America, Europe, East Asia, North America
- Affects Middle aged people to elderly people
- Males are more affected than females
- Presence of fever, headache, rash, arthralgia, diarrhea, conjunctivitis before the onset of Guillain-Barre syndrome
- Takes 0–10 days to develop Guillain-Barre syndrome
- Facial Diplegia common >50% cases
- Dysautonomia common up to 30% cases
- Outcome is good, half may require ICU care
Epidemiology and Demographic
- Five cases of Guillain-Barre syndrome (GBS) in patients with COVID-19 has been reported in three hospitals in Northern Italy from February 28 through March 21, 2020. Four of these patients had a positive nasopharyngeal swab for SARS-CoV-2 at the onset of the neurologic syndrome, and one had a negative nasopharyngeal swab and negative bronchoalveolar lavage but subsequently he developed a positive serologic test for the virus [2].
- The first official case of Guillain-Barre syndrome (GBS) associated in patients with COVID-19 in the United States has been reported by neurologists from Allegheny General Hospital in Pittsburgh, Pennsylvania in June,2020.The patient was a 54-year-old man who was transferred to Allegheny General Hospital after developing ascending limb weakness and numbness that followed symptoms of a respiratory infection.The man reported that his wife was tested positive for COVID-19 infection and that his symptoms started soon after her illness. Later he also tested positive for COVID-19.[7]
- Another case of Guillain–Barre syndrome with COVID-19 has been reported in Iran[8].
- Five cases of Guillain-Barre syndrome (GBS) in patients with COVID-19 has been reported in three hospitals in Northern Italy from February 28 through March 21, 2020. Four of these patients had a positive nasopharyngeal swab for SARS-CoV-2 at the onset of the neurologic syndrome, and one had a negative nasopharyngeal swab and negative bronchoalveolar lavage but subsequently he developed a positive serologic test for the virus [2].
Screening
- There is insufficient evidence to recommend routine screening for COVID-19 associated Guillain-Barre Syndrome.
Diagnosis
History and Symptoms:
- The classic clinical manifestations of Guillain-Barre syndrome is
- Progressive, ascending, symmetrical flaccid limbs paralysis
- Areflexia or hyporeflexia and with or without cranial nerve involvement, which can progress over the course of days to several weeks
- In the Italian cases, Guillain-Barre syndrome symptoms began 5-10 days after the first COVID-19 symptoms. The first symptoms of GBS were lower limb weakness in four patients and facial diplegia with subsequent ataxia and paresthesia in one patient. Four patients had generalized flaccid tetraparesis or tetraplegia that developed over 3 to 4 days; No patient had dysautonomic features.[2]
| Patient no. | Onset of neurologic symptoms |
Neurologic Signs & Symptoms [9] |
|---|---|---|
| 1 | 7 days after fever, cough, ageusia | Flaccid areflexic tetraplegia evolving to facial weakness, upper limb paresthesia(36 hr), and respiratory failure(day 6) |
| 2 | 10 days after fever and pharyngitis | Facial diplegia and generalized areflexia evolving to lower limb paresthesia with ataxia (Day 2) |
| 3 | 10 days after fever and cough | Flaccid tetraparesis and facial weakness evolving to areflexia (day 2) and respiratory failure( day 5) |
| 4 | 5 days after cough and hyposmia | Flaccid areflexic tetraparesis and ataxia (day 4) |
| 5 | 7 days after cough,ageusia and anosmia | facial weakness,flaccid areflexic paraplegia(day 2-3) and respiratory failure (day 4) |
- In the US case, the deficits in the 54 year old man were characterized by quadriparesis and areflexia, burning dysesthesias, mild ophthalmoparesis, and dysautonomia. He did not have the loss of smell and taste documented in other COVID-19 patients.[3]. The unique clinical features in the US case are urinary retention secondary to dysautonomia and ocular symptoms of diplopia.[3]
Laboratory Findings
- The findings of five Italian patients with Guillain- Barre syndrome after the onset of COVID-19 infection:[2]
| Patient no.[2] | CSF findings [2] |
Antiganglioside Antibodies [2] |
MRI Findings[2]
|
|---|---|---|---|
| 1 |
|
Negative |
|
| 2 |
|
Not tested |
|
| 3 |
|
Negative |
|
| 4 |
|
Not tested |
|
| 5 |
|
Negative |
|
Treatment
- All patients were treated with Intravenous Immune globulin
- Plasmapheresis can also be done
Prognosis
- Among the five Italian patients of Covid-19 associated GBS two patients had poor outcome including ICU admission due to respiratory failure,they remained in intensive care after 4 weeks of treatment ;two patients had mild improvement and receiving physical therapy, and one was discharged walking independently.[10][2]
- The only US patient with COVID-19 associated GBS briefly required mechanical ventilation and was successfully weaned after receiving a course of Intravenous Immunoglobulin.[3]
References
- ↑ Meng X, Deng Y, Dai Z, Meng Z (June 2020). "COVID-19 and anosmia: A review based on up-to-date knowledge". Am J Otolaryngol. 41 (5): 102581. doi:10.1016/j.amjoto.2020.102581. PMC 7265845 Check
|pmc=value (help). PMID 32563019 Check|pmid=value (help). - ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Toscano, Gianpaolo; Palmerini, Francesco; Ravaglia, Sabrina; Ruiz, Luigi; Invernizzi, Paolo; Cuzzoni, M. Giovanna; Franciotta, Diego; Baldanti, Fausto; Daturi, Rossana; Postorino, Paolo; Cavallini, Anna; Micieli, Giuseppe (2020). "Guillain–Barré Syndrome Associated with SARS-CoV-2". New England Journal of Medicine. 382 (26): 2574–2576. doi:10.1056/NEJMc2009191. ISSN 0028-4793.
- ↑ 3.0 3.1 3.2 3.3 "First Reported US Case of Guillain-Barré Linked to COVID-19".
- ↑ 4.0 4.1 4.2 4.3 Gupta A, Paliwal VK, Garg RK (July 2020). "Is COVID-19-related Guillain-Barré syndrome different?". Brain Behav. Immun. 87: 177–178. doi:10.1016/j.bbi.2020.05.051. PMC 7239011 Check
|pmc=value (help). PMID 32445789 Check|pmid=value (help). - ↑ Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, Xie X, Yin W, Li H, Liu M, Xiao Y, Gao H, Guo L, Xie J, Wang G, Jiang R, Gao Z, Jin Q, Wang J, Cao B (February 2020). "Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China". Lancet. 395 (10223): 497–506. doi:10.1016/S0140-6736(20)30183-5. PMC 7159299 Check
|pmc=value (help). PMID 31986264. - ↑ 6.0 6.1 Sedaghat Z, Karimi N (June 2020). "Guillain Barre syndrome associated with COVID-19 infection: A case report". J Clin Neurosci. 76: 233–235. doi:10.1016/j.jocn.2020.04.062. PMC 7158817 Check
|pmc=value (help). PMID 32312628 Check|pmid=value (help). - ↑ "Frontiers | Neurological Manifestations of COVID-19 (SARS-CoV-2): A Review | Neurology".
- ↑ "Guillain–Barré Syndrome Associated with SARS-CoV-2 | NEJM".
- ↑ "NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals".