|Year : 2021 | Volume
| Issue : 1 | Page : 34-36
Guillain-barre syndrome and posterior reversible encephalopathy syndrome associated with COVID-19: Expanding horizon of the novel disease
Sunil Chaudhary, Mithu Bhowmick, Ashok Kumawat, Gaurav Singh
Department of Medicine, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Submission||11-Oct-2020|
|Date of Decision||31-Oct-2020|
|Date of Acceptance||31-Oct-2020|
|Date of Web Publication||12-Jan-2021|
Dr. Mithu Bhowmick
Department of Medicine, VMMC and Safdarjung Hospital, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
On late December 2019, an epidemic of cases with unexplained pneumonia was first detected in Wuhan, China. Subsequently, the etiological agent was attributed to a novel coronavirus SARS-CoV-2, also designated as COVID-19. The disease primarily affects the respiratory tract, but involvement of the cardiovascular system, neurological system, gastrointestinal system, and renal system had been reported. Here, we report the case of a 60-year-old female who presented with progressive ascending pattern weakness of both lower limbs associated with the symptoms of severe headache and blurring of vision, which progressed to such an extent that she could only perceive light. Two weeks prior to hospitalization, she had fever, sore throat, dry cough, and myalgia. Subsequently, she tested positive for COVID-19 by? reverse transcription-polymerase chain reaction and imaging, and electrodiagnostic study was performed which was suggestive of Guillain–Barré syndrome (GBS) and posterior reversible encephalopathy syndrome (PRES). She was treated with intravenous immunoglobulin and antihypertensive medications, which resulted in a dramatic improvement of her symptoms. There had been reported cases of GBS and PRES associated with COVID-19 separately. However, this may be the first case report of concurrent occurrence of both the syndromes in a patient with the novel disease.
Keywords: COVID-19, Guillain–Barré syndrome, posterior reversible encephalopathy syndrome
|How to cite this article:|
Chaudhary S, Bhowmick M, Kumawat A, Singh G. Guillain-barre syndrome and posterior reversible encephalopathy syndrome associated with COVID-19: Expanding horizon of the novel disease. Indian J Med Spec 2021;12:34-6
|How to cite this URL:|
Chaudhary S, Bhowmick M, Kumawat A, Singh G. Guillain-barre syndrome and posterior reversible encephalopathy syndrome associated with COVID-19: Expanding horizon of the novel disease. Indian J Med Spec [serial online] 2021 [cited 2022 Jan 26];12:34-6. Available from: http://www.ijms.in/text.asp?2021/12/1/34/306742
| Introduction|| |
SARS-CoV-2, also designated as COVID-19, is a single-stranded RNA virus belonging to betacoronavirus of Orthocoronaviridae family. The virus exerts its action by binding to ACE2 receptors and results in a cytokine storm. The disease is highly contagious and had spread globally, forcing a worldwide lockdown and social distancing. The clinical spectrum of the disease ranges from mild upper respiratory tract symptoms to respiratory failure, requiring invasive ventilation and multiorgan failure. The disease runs a severe course in the elderly and in patients with comorbid illness. There had been reported cases of Guillain–Barré syndrome (GBS) and posterior reversible encephalopathy syndrome (PRES) associated with COVID-19 separately. However, this may be the first case report of concurrent occurrence of both the syndromes in a patient with the novel disease.
| Case Report|| |
A 60-year-old female without any history of comorbid illness presented with the complaint of sudden-onset weakness of both lower limbs for 4 days. She first noticed her weakness in the distal lower limb after getting up from bed in the morning, and over a 24 h course, it progressed to involve the proximal lower limb as well. Two days after the onset of weakness, she had severe headache and blurring of vision, and it progressed to such an extent that she could only perceive light. She gave a preceding history of fever, sore throat, dry cough, and myalgia about 6 days back, before the onset of her neurological symptoms. On clinical examination, her blood pressure was found to be 160/96 mmHg and ocular examination revealed only perception of light in the bilateral eyes with normal pupillary reflex and fundus. Motor examination of the lower limb was suggestive of areflexic paralysis with a power of 1/5 in both lower limbs. Bilateral plantar was mute. The sensory system was intact. Examination of the upper limb was unremarkable. Her single breath count was within normal limits. Her complete blood count; liver function test; renal function test; serum electrolytes; and serological studies for HIV, HbsAg, and anti-HCV were all within normal limits. Nasopharyngeal swab for COVID-19 was positive by? reverse transcription-polymerase chain reaction. Contrast-enhanced magnetic resonance imaging (MRI) brain revealed T2-weighted fluid-attenuated inversion-recovery asymmetric hyperintensities in the bilateral parieto-occipital white matter (left > right), suggestive of PRES [Figure 1]. Electrodiagnostic parameters demonstrated decreased conduction velocity and absent F-waves and H reflex in the common peroneal nerve and posterior tibial nerve of both lower limbs, which were suggestive of acute inflammatory demyelinating polyradiculopathy. Based on clinical findings, imaging, and electrodiagnostic study, a presumptive diagnosis of GBS and PRES associated with COVID-19 was made. She was treated with intravenous immunoglobulin at 2 g/kg divided over 5 days and antihypertensive medications. At day 7 of hospital stay, she had improvement in her vision and power of both lower limbs improved to 3/5.
|Figure 1: Contrast-enhanced magnetic resonance imaging brain showing T2-weighted fluid-attenuated inversion-recovery asymmetric hyperintensities in the bilateral parieto-occipital white matter (left > right), suggestive of posterior reversible encephalopathy syndrome|
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| Discussion|| |
GBS is an acute paralytic peripheral neuropathy with an annual incidence of 0.8–1.9 cases/100,000 people/year. Various antecedent infectious (Campylobacter jejuni, Mycoplasma pneumoniae, EB virus, etc.) and noninfectious agents (vaccines) have been implicated as a trigger for the disease. The pathophysiology is linked to molecular mimicry between microbial and host antigen, leading to aberrant immunological response targeting spinal roots and peripheral nerves. The disease runs a monophasic course and presents with acute flaccid paralysis which usually starts in the distal lower extremities and ascends proximally. Respiratory failure can develop in 20%–30% of patients requiring invasive ventilation. The diagnosis of GBS is established using Brighton criteria which include clinical assessment, nerve conduction studies, cerebrospinal fluid (CSF) findings, and exclusion of other causes. CSF picture commonly reveals albumin cytological dissociation, but CSF may be normal if obtained in the 1st week of illness. Our case meets Brighton criteria-level 2 of diagnostic certainty. Intravenous immunoglobulin and plasma exchange are currently considered the standard of care in GBS. A similar case was also described by Sedaghat and Karimi in a 65-year-old male patient, where the patient was treated with intravenous immunoglobulin.
PRES is a neuroradiological entity characterized by headache, vision loss, seizures, and altered mental status. The common causes include acute hypertension, eclampsia, preeclampsia, renal disease, and autoimmune disease. Typical MRI brain finding reveals focal symmetric edema commonly involving the parietal and occipital lobes. The exact pathology remains unclear, and probable hypotheses suggest failure of cerebral autoregulation, endothelial damage, and cerebral vasoconstriction as the predominant mechanisms. Kishfy et al. reported two cases of association of PRES with COVID-19, and presumed endothelial dysfunction caused by COVID-19 as the contributing mechanism. Another case of PRES associated with GBS was described by Banakar et al. where the authors postulated dysautonomia secondary to GBS as the proposed mechanism. However, the association of PRES with COVID-19 could be due to endothelial dysfunction caused by COVID-19 per se or it may be due to dysautonomia as a result of GBS., The exact pathogenesis remains unknown.
Our case report should enlighten the treating physician about the widening spectrum of COVID-19, and should prompt for early diagnosis and treatment to minimize neurological complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There were no conflicts of interest.
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