A concomitant Guillain-Barre Syndrome with COVID- 19: a rst case-report in Colombia

Nuvia Mackenzie Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia Eva Lopez-Coronel Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia Alberto Dau Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia Dieb Maloof Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia Salvador Mattar Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia Jesus Tapia Garcia Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia Briyis Fontecha Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia Cristina Lanata Rosalind Russell/Ephraim P Engleman Rheumatology Research Center, University of California, San Francisco, San Francisco, California, USA Hernan Felipe Guillen-Burgos (  hernan.guillen@unisimonbolivar.edu.co ) Center for Clinical and Translational Research, La Misericordia Clinica Internacional, Barranquilla, Colombia

with a history of progressive general weakness with lower limb dominance. A previous symptom as ageusia, anosmia and intense headache was reported. On admission, facial diplegia, quadriparesis with lower limbs predominance and Medical Research Council Scale 2/5 in lower limbs and 4/5 in upper limbs was reported. During clinical evolution, due to general are exia, hypertensive emergency and progressive diaphragmatic weakness, the patient was admitted to intensive care unit. Cerebrospinal Serum Fluid revealed protein-cytologic dissociation and electromyography test were compatible with Guillain-Barre Syndrome. By symptoms before hospitalization, SARS-CoV2 diagnostic testing was performed with positive result in second test. Management to COVID-19 and Guillain Barre Syndrome was performed and patient was discharged after 20 days of hospitalization with clinical improvement.

Case Presentation
During midterm of April 2020, a 39 years old woman was admitted after with a 6 days history of progressive general weakness, with predominance in lower limbs. Twenty days prior admission, she began with ageusia, anosmia and intense headache with multiples consultations to external emergency rooms without improvement of symptoms. She then developed intense myalgias and leg weakness, which progressed to impossibility to walk for which she was referred to our hospital. On admission, the patient reported headache, malaise, general myalgias, cough and failure to walk. Her vital signs were blood pressure of 167/88 mmHg, heart rate 74 beats per min, respiratory rate 18 breaths per min and SaO2 95%. She was found to have facial diplegia, quadriparesis with lower limbs predominance, Medical Research Council (MRC) muscular strength 2/5 in lower limbs and 4/5 in upper limbs. During the clinical evolution she had general are exia and left arm paresthesia. Her past medical history was signi cant for hypertension, type 2 diabetes mellitus, and cholecystectomy. She was admitted to the intensive care unit due to hypertensive emergency, and progressive diaphragmatic weakness. Initial laboratory tests are shown in Table 1 which were remarkable for leukocytosis, neutrophilia, LDH and D-Dimer elevated. CSF analysis revealed protein-cytologic dissociation. Chest X-ray and chest CT scan were normal. An electromyography test (Table 2) con rmed the clinical evaluation of a GBS diagnosis. The patient was managed with supportive care, and plasmapheresis for 5 days, one session per day. After 3 sessions, the patient had neurologic improvement. During the hospitalization the patient had two nasal swabs tested for SARS-CoV2. First RT-PCR for SARS-CoV2 was negative, however, second RT-PCR SARS-CoV2 had positive result. She received hydroxychloroquine, 400mg twice rst day, continue with 200 mg BID per 10 days plus dexamethasone 8mg every eight hours during 3 days, and standard care. She did not require supplemental oxygen and no alterations were evidenced in chest images. She was discharged after 20 days of hospitalization with improvement of neurologic (MRC 4/5 in lower limbs) and respiratory symptoms.

Discussion And Conclusion
Neurological outcomes have been reported in patients with COVID-19. The neurological manifestations range from headache, dizziness, confusion, and although with few cases, more severe conditions such as encephalopathy, acute disseminated encephalomyelitis, and Guillain-Barre Syndrome, among others [5].
GBS is a neuroin ammatory disease with a global incidence of 1-2 per 100,000 person-years [6]. GBS is the most common cause of acute accid paralysis and diagnosis included patient history, neurological examination, electrophysiological test and cerebrospinal serum uid (CSF) analysis [6]. Several viral and bacterial pathogens have been found in GBS patients in case-control studies but there are do not clarity in what triggers the immune-mediated destruction of nerve tissue [7]. Pathogens such as Cytomegalovirus, Epstein-Barr virus, Mycoplasma Pneumonia, Zika Virus, and the novel Coronavirus SARS-CoV2 has been reported with previous exposition to these agents and GBS outcome [8,9,10,11,12] The rst case of GBS and COVID-19 was reported in a patient with travel history to Wuhan [13] followed by other cases in countries with high incidence of SARS-CoV2 such as Italy [12], Iran [14] and Spain [15]. A possible hypothesis of GBS triggered by COVID-19 has been proposed, however only fewer cases has been reported. We speculate that whether the incidence of cases would be increasing and follow-up of recovered patients is conducted focusing on identify neurological outcomes, polyneuropathies as GBS could be found it. There is no certainty whether the infection preceded the GBS, or whether the infection is concomitant or is casualty in this group of patients. More studies are needed to determine if COVID-19 has a direct association with GBS, such as previous reported association with Zika Virus [11]. During the last outbreak of Zika Virus (ZIKV) in Colombia, the researchers reported virologic evidence of ZIKV in patients with GBS in Colombia [11].
In summary, we report the rst case of GBS concomitant with COVID-19 in Colombia, with a favorable outcome. As the pandemic continues to unfold, we shall be able to see if there is a rise in GBS cases, supporting this potential association.

Consent for publication
Written informed consent was obtained from the patient for publication as a case-report with anonymized data.