Guillain-Barré syndrome associated with SARS-CoV-2 infection: A case series from 4 Colombian cities during the pandemic

Abstract

SARS-CoV-2 infection has been associated with multiple neurological manifestations. One such manifestation, which has been described since the early stages of the COVID-19 pandemic and is relevant for current neurological practice, is Guillain-Barré syndrome (GBS). The literature describes neurotoxic mechanisms of the virus itself and the possible pathways by which it may affect the peripheral nerves in experimental studies; however, we still lack information on the mechanisms causing the immune response that gives rise to GBS in the context of SARS-CoV-2 infection. Colombia is one of the Latin American countries worst affected by the pandemic, with the third-highest number of cases in the region; thus, it is essential to recognise GBS, as this potential postinfectious complication may severely compromise the patient’s functional status in the absence of timely diagnosis and treatment. We present a series of 12 cases of GBS associated with SARS-CoV-2 infection from hospitals in 4 different Colombian cities and describe the clinical presentation, laboratory and electrophysiological study findings, and treatment.

Resumen

En el año 2020 se declaro la pandemia ocasionada por la infección por el virus SARSCoV-2, virus de la familia del coronavirus, adoptándose el nombre de COVID-19 a la enfermedad 1. En Bogotá, Colombia, se confirmó el primer caso de COVID-19 el 6 de marzo de 2020 (2). Los principales síntomas reportados en la infección por SARSCoV-2 son fiebre (43.8% en la admisión y 88.7% durante la hospitalización) y tos (67.8%) (3). Otros síntomas encontrados son fatiga (38.1%), producción de esputo (33.7%) y cefalea (13.6%). Los principales signos neurológicos reportados en los pacientes con infección severa por SARS-Cov-2 son agitación (69%), compromiso en tracto corticoespinal (67%) y delirium (65%) (4). Las principales complicaciones neurológicas descritas asociadas a Covid 19 son: anosmia, disgeusia, encefalopatia, Síndrome de Guillain Barre, complicaciones cerebrovasculares y daño en musculo esquelético (5–8).

En el presente articulo se presenta una serie de casos de pacientes con síndrome de Guillain-Barré asociado a infección por SARS-CoV-2. Se recolectaron casos de diferentes instituciones medicas de Colombia.

Introduction

The COVID-19 pandemic associated with the novel coronavirus SARS-CoV-2 was declared in 2020. The first confirmed case of COVID-19 in Bogota (Colombia) was recorded on 6 March 2020. The main symptoms reported are fever (43.8% of cases at admission and 88.7% during hospitalisation) and cough (67.8%). Other symptoms include fatigue (38.1%), sputum production (33.7%), and headache (13.6%). The main neurological signs reported in patients with severe COVID-19 are agitation (69%), corticospinal tract involvement (67%), and delirium (65%). The main neurological complications associated with the disease are anosmia, dysgeusia, encephalopathy, Guillain-Barré syndrome (GBS), cerebrovascular complications, and skeletal muscle damage.

We present a series of cases of GBS associated with SARS-CoV-2 infection. Cases were gathered from several Colombian hospitals.

Methods

We conducted a descriptive case series study between 2020 and 2021, gathering data from the following hospitals: Fundación Cardioinfantil (Bogota), Fundación Santafe de Bogotá (Bogota), Clínica Medilaser (Neiva), Clínica San Luis (Bucaramanga), and Clínica Ospedale (Manizales). The following inclusion criteria were established: age older than 18 years; clinical and electrophysiological diagnosis of acute neuropathy according to the Asbury criteria; symptoms suggestive of SARS-CoV-2 infection between 1 week and 2 months prior to or coinciding with acute neurological symptoms; or documented positive SARS-CoV-2 test result (antigen, polymerase chain reaction [PCR], or FilmArray respiratory panel) at the time of neuropathy or within a month before onset of weakness.

Results

Table 1 presents the main clinical and laboratory characteristics of patients with GBS associated with SARS-CoV-2 infection.

Table 1

Patients with Guillain-Barré syndrome and SARS-CoV-2 infection. Clinical, electrophysiological, and laboratory characteristics.

Patient	Sex	Age (years)	Previous respiratory/gastrointestinal symptoms	Time to onset of neurological symptoms (days)	Pneumonia	Neurological signs/symptoms	Diagnosis of SARS-CoV-2 infection	CSF	EMG + NCS	Level of certainty (Brighton level)	Treatment	Modified Rankin Scale score at discharge (0 to 6)
1	M	55	Cough, odynophagia, diarrhoea	30	No	Sudden-onset dysarthria, facial diplegia	11/04/20 positive PCR	Proteins: 210 mg/dL; leukocytes: 0	Severe acute axonal neuropathy of the left and right facial nerves with involvement of the frontal, zygomatic, buccal, and marginal mandibular branches	1	None	1
2	M	73	Diarrhoea	7	No	Loss of muscle strength in all 4 limbs with inability to walk, loss of mobility Areflexia	28/09/20 positive PCR	Proteins: 55 mg/dL; leukocytes: 2.5 cells/μL (100% mononuclear)	Acute motor axonal polyradiculoneuropathy with minimal signs of acute denervation	1	IV immunoglobulins	3
3	M	54	Fever, diarrhoea	5	No	Neck and lumbar pain, upper and subsequently lower limb weakness, myalgia	01/10/20 positive FilmArray respiratory panel	Proteins: 67.4 mg/dL; leukocytes: 0	Demyelinating sensorimotor polyneuropathy, intrinsic muscle fibre disease	2	IV immunoglobulins	4
4	M	51	None	NA	No	Intense lumbar pain irradiating to the posterior aspect of both legs with progressive lower limb weakness and subsequent paraesthesia of the hands	21/10/20 positive PCR	Proteins: 149 mg/dL; leukocytes: 0	Demyelinating polyradiculoneuropathy with predominant lower limb involvement	2	Plasma exchange	3
5	M	62	Ageusia	1	No	Predominantly occipital holocranial pressing headache, bilateral labial commissure deviation, right-sided hemiparesis, dysarthria, dysphagia, areflexia, glove-and-stocking paraesthesia	26/10/20 negative SARS-CoV-2 antigen test 03/11/20 positive PCR	ND	Predominantly axonal sensorimotor polyneuropathy	3	IV immunoglobulins	3
6	W	57	Cough, dyspnoea, anosmia	20	Yes	Impaired level of consciousness, flaccid quadriparesis, areflexia	12/12/20 positive PCR	Proteins: 52.8 mg/dL; leukocytes: 0	20/01/21 acute demyelinating sensorimotor polyneuropathy	2	Plasma exchange	5
7	W	61	Yes	15	No	Progressive ascending lower limb weakness with generalised hypoaesthesia, fall from standing height	10/01/21 positive PCR	Proteins: 147 mg/dL; glucose: 175 mg/dL (central: 271 mg/dL); leukocytes: 2 cells/μL	Symmetrical motor axonal polyneuropathy	1	Plasma exchange	3
8	W	71	None (close contact)	NA	No	Paraesthesia, burning pain (proximal and subsequently distal in lower limbs, peripheral facial nerve territory)	20/02/21 inconclusive PCR; 22/02/21 positive PCR	Proteins: 230 mg/dL; leukocytes: 2.5 cells/μL	Predominantly demyelinating polyneuropathy with symmetrical motor involvement	1	Plasma exchange	3
9	M	57	Fever, diarrhoea	8	No	Lower limb paraesthesia, inability to walk, urinary incontinence, paraesthesia of the hands, areflexic flaccid paraparesis, glove-and-stocking hypoaesthesia, sensory ataxia	22/10/20 positive PCR	Proteins: 288 mg/dL; Leukocytes: 0		2	Plasma exchange	3
10	M	43	Dysphagia, fever	15	No	Limb paraesthesia, facial diplegia	18/07/20 positive PCR	ND	Predominantly demyelinating acute sensorimotor polyneuropathy with an axonal component, mild severity, with more marked involvement of the cranial nerves. Given the clinical context, these findings suggest acute inflammatory demyelinating polyneuropathy	2	None	2
11	W	42	Fever, joint pain	8	No	Facial diplegia Paraesthesia in all 4 limbs Readmission: difficulty walking	20/07/21 positive PCR	26/07/21 CSF: proteins: 67 mg/dL; glucose: 59 mg/dL; leukocytes: 0 28/08/21 proteins: 220 mg/dL; glucose: 57 mg/dL; leukocytes: 1 cell/μL	Acute demyelinating sensorimotor polyneuropathy (segmental demyelination) with a secondary axonal component, mild severity, with more marked involvement of the facial nerves. Findings suggest acute inflammatory demyelinating polyneuropathy	1	IV immunoglobulins	3
12	M	38	Cough, fever, dysphagia	45	No	Dysphagia Weakness in the lower limbs Unable to walk	15/05/21 positive PCR	ND	Acute motor axonal polyneuropathy with a demyelinating component, moderate severity	2	IV immunoglobulins	2