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Guillain Barr Syndrome As A Neurological.5
Guillain Barr Syndrome As A Neurological.5
Guillain Barr Syndrome As A Neurological.5
was spare. In addition, F and H waves were absent. Electromyography neurological examination of the girl was notable for generalized
showed reduced recruitment in all limbs without evidence of sponta- hyporeflexia and decreased light touch sensation in distal limbs. Her
neous activity. The findings were consistent with acute axonal- father revealed the same examination with mild bilateral facial paresis.
demyelinating polyradiculoneuropathy.
On hospital day 3, the illness evolved with autonomic features as
the patient developed tachycardia and blood pressure instability. In DISCUSSION
addition, the patient developed bulbar involvement in a way he was Coronaviruses are enveloped nonsegmented positive-stranded
unable to swallow, accompanied by severely slurred speech. The re- RNA viruses belonging to the family Coronaviridae that are mainly
examination was notable for the bilaterally reduced gag reflex. attached to the cellular receptor angiotensin-converting enzyme 2
Subsequently, treatment started with therapeutic plasma exchange
(TPE). We did a total of 5 sessions of TPE (alternate days). One
(ACE2) receptors located in the nasal epithelium and lower res-
standard TPE session was 2.5 plasma volume exchange using 5% piratory airways leading to respiratory symptoms. Nevertheless,
albumin as a replacement fluid. Furthermore, labetalol by intravenous under poorly understood conditions, it could also invade the
bolus was administered to control the sympathetic nervous system over- nervous system.4,7,8 There are limited reports of neurological
reactivity, which was successfully controlled over 24 hours. complications of COVID-19 in the literature. The study of Wei
Meanwhile, his 14-year-old daughter presented with a history of et al8 reported a case of COVID-19 with a primary manifestation
progressive ascending quadripareshtesia since 2 days before admission, being third nerve palsy. The study of Filatov and colleagues9
which was accompanied by mild lower limb weakness. Similar to her reported a case of COVID-19 presenting with acute encephalop-
father, she complained of headaches and dizziness. The neurological athy who was first diagnosed with chronic obstructive pulmonary
examination was within normal in cranial nerves. The motor system
assessment revealed the power muscle grade 4/5 in lower limbs,
disease exacerbation. However, regarding the unexplained ence-
affecting both the distal and proximal muscles and 5/5 in upper limbs. phalopathy and outbreak of the novel emerging virus, the suspicion
The deep tendon reflexes were hypoactive in upper limbs and absent in of COVID-19 was proposed, which was eventually confirmed by
lower limbs, respectively. The sensory examination was notable for a polymerase chain reaction assay. More recently, a report of acute
decreased light touch, position, and vibration sensation in all distal necrotizing encephalopathy associated with COVID-19 has been
limbs up to ankle and elbow joints. The patient was ambulatory, published. The patient was an elderly woman with COVID-19 who
however, she became ataxic with closed eyes. went under brain imaging because of considerable loss of con-
Again, all the ancillary examinations were within normal limits sciousness. The brain magnetic resonance imaging demonstrated
except for the albuminocytologic dissociation in the CSF. It should be hemorrhagic rim enhancing lesions within the bilateral thalami,
noted that the electromyography-nerve conduction study has not yet
carried out for the patient. In the following, the patient was hospitalized
medial temporal lobes, and subinsular regions which was com-
in ICU and intravenous immunoglobulin (20 g intravenously daily for patible with acute necrotizing encephalopathy.10
5 d) was instituted. On the other hand, it should be noted that GBS is a rare
Taking all considerations into account—familial aggregation, acute immune-mediated polyradiculoneuropathy with an inci-
history of upper respiratory infection in all family members, familial dence rate of 0.6 to 4 cases per 100,000 annually. The exact
presentation of GBS, and an outbreak of novel coronavirus pneumonia etiology of GBS is unknown. However, in ~50% of the cases, a
—COVID-19 was suspected. The polymerase chain reaction assay of specific type of preceding infection could be identified in which
throat swab sample was positive for COVID-19 in both patients. C-Jeiuni is of paramount importance.11,12 Furthermore, it is
As a final point, according to the epidemiologic characteristics, noteworthy that the familial occurrence of GBS is a rare event
clinical features, and paraclinical findings, the diagnosis of GBS in
association with COVID-19 was made.
and only a few articles have been published so far.13
The treatment started with oral hydroxychloroquine sulfate In the cases we described, the neurological complication was
200 mg two times per day for a week. The therapeutic course has been confined to the peripheral nervous system that has not been
fulfilled in ICU. No more hemodynamic instability occurred. Neuro- reported so far. The occurrence of polyneuropathy could be
logical symptoms gradually improved. Eventually, they transferred to explained by the aberrant autoimmune response targeting the
the neurology ward and discharged with a good general condition. The peripheral nerves regarding the microbial and host factors.14
However, our patients were unique in that both of them belonged
to the family with the same antecedent history of flu-like symptoms
TABLE 2. Sensory Nerve Conduction Study before the presentation.
Amplitude Conduction The present report indicates the diverse neurological
Latency (ms) (micro V) Velocity (m/s) manifestations of COVID-19 that highlights the importance of
neurological assessment in patients with COVID-19.
Nerve Right Left Right Left Right Left
Median Absent Absent Absent Absent Absent Absent CONCLUSIONS
Ulnar Absent Absent Absent Absent Absent Absent
Sural 3.0 3.0 10 10 55 55 COVID-19 infection is considered as a global pandemic
because of the high potential of transmissibility. There is
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The Neurologist Volume 25, Number 4, July 2020 COVID-19 and Familial Guillain-Barré Syndrome
evidence suggesting the neuroinvasive potential of COVID-19. case series study. 2020. Doi: https://doi.org/10.1101/2020.02.22.20
However, there is no report of COVID-19 association with 026500.
GBS in the literature. Herein, we described 2 unique events: an 7. Desforges M, Le Coupanec A, Dubeau P, et al. Human coronaviruses
occurrence of familial GBS after recovery phases of COVID-19 and other respiratory viruses: underestimated opportunistic pathogens of
the central nervous system? Viruses. 2019;12:14.
infection. 8. Wei H, Yin H, Huang M, et al. The 2019 novel cornoavirus
pneumonia with onset of oculomotor nerve palsy: a case study.
J Neurol. 2020;267:1550–1553.
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