In this study, we reported Guillain Barre Syndrome in two patients infected with Covid-19. The first ever case of novel coronavirus (Covid-19) was noted in Wuhan City, Hubei Province of China. It is a new beta coronavirus that gains access inside the cell by binding with angiotensin- converting enzyme 2 (ACE2) receptor. Covid 19 can cause variety of symptoms, amongst which respiratory complications similar to severe acute respiratory complications are mostly seen that include fever, cough, dyspnea, myalgia and headache.
Besides respiratory system involvement, other systems are known to be involved that produces symptoms such as diarrhea, gastrointestinal complications, acute cardiac damage and acute renal failure.
Coronavirus is a neurotropic and neuroinvasive virus that stimulates inflammatory cells that leads to production of various inflammatory cytokines creating an immune mediated process. GBS being an immune mediated disorder can be caused by molecular mimicry.
The neurologic manifestations of COVID-19 span a large spectrum ranging from anosmia, ageusia, encephalopathy, encephalitis, myelitis to post infectious complications like Guillain Barre Syndrome (GBS), plexopathies and cranial neuropathies 2.
One postulated route for entry of Severe Acute Respiratory Syndrome Coronavirus 2 infection (SARSCoV2) into the central nervous system (CNS) is trans-synaptic travel from the olfactory epithelium 3. The entry into the CNS is mediated by the endothelial ACE2 (angiotensin-converting enzyme 2) receptors in brain vessels 4. The haematogenous route is another source of spread to the CNS 5. In these cases, the virus is probably introduced into the CNS via a leaky blood brain barrier.
However, in the cases of GBS reported by Dalakas et al, among the 7/11 patients tested, there was no virus detected in the cerebrospinal fluid, thus ruling out direct infection of the roots 2. Thus, the pathogenesis is most likely immune mediated. GBS has been described with several infectious agents in the past. The commonly reported viruses are influenza, cytomegalovirus, Ebstein-Barr virus, herpes simplex virus, enteroviruses, hepatitis viruses and HIV 2. GBS has previously been reported with other coronaviruses 6. One study described an increased incidence of GBS at their centre during the COVID-19 pandemic 7, but this has not been seen by others 8.
Several case series of adult patients have been published over the course of the ongoing COVID-19 pandemic. Some of them are listed below (Table 1). Data on children is scanty.
Table 1
Summary of case series of patients of Covid-19 with neurologic manifestations
S no | Authors | Cases | Additional Comments |
1 | Toscano and colleagues (9) (Italy) | Treated five patients with GBS after onset of COVID-19 disease. All of them were treated with IVIG; two of them needed a second course of IVIG and one also needed to be started on plasma exchange. | The need for a second course of IVIG is similar to the course of one of our patients. |
2 | Paterson et al (10) (London) | Reported 43 cases (ages 16–85 years) with COVID-19 related neurologic disorders. Of these seven were cases of GBS. All of them received IVIG and the majority showed partial and ongoing recovery. | Case 2 showed partial recovery |
3 | Frontera and colleagues (11) (New York City) | Described 606 cases (ages 57–83 years) with neurologic disorders in patients hospitalized with SARSCoV2 infection. Three of these cases had GBS. | |
4 | In the French NeuroCOVID registry (12) | Among the 222 patients with neurologic manifestations of Covid-19 (age 53–72 years) GBS was seen in 15. Fourteen of these were treated with IVIG and two required mechanical ventilation. | |
5 | CoroNerve study group (13). (United Kingdom) | In a United Kingdom-wide surveillance study conducted by the CoroNerve study management group, neurological and neuropsychiatric complications of COVID-19 in 153 patients were studied (age range 23–94 years). Out of these, four patients were diagnosed to be suffering from GBS and its variants. | |
Both the cases reported by us had classic symptomatology of GBS, and case 1 presented almost two weeks after Covid – 19. The latency of disease onset cannot be ascertained in case 2 because he had no initial manifestations of Covid-19.
Many patients with GBS do not have any COVID-19 symptoms at presentation 2. Dalakas et al suggest that the diagnosis should be especially suspected in cases with anosmia, ageusia, cranial neuropathies, or lymphocytopenia. The latent period between onset of symptoms of COVID-19 and the onset of GBS has also been variable. Some researchers have reported an earlier than usual onset of symptoms following infection 9,14,15 while others have described a more typical latent period 8.