Clinical neurophysiology and cerebrospinal liquor analysis to detect Guillain‐Barré syndrome and polyneuritis cranialis in COVID‐19 patients: A case series

Abstract

We report a case series of five patients affected by SARS‐CoV‐2 who developed neurological symptoms, mainly expressing as polyradiculoneuritis and cranial polyneuritis in the 2 months of COVID‐19 pandemic in a city in the northeast of Italy. A diagnosis of Guillain‐Barré syndrome was made on the basis of clinical presentation, cerebrospinal fluid analysis, and electroneurography. In four of them, the therapeutic approach included the administration of intravenous immunoglobulin (0.4 g/kg for 5 days), which resulted in the improvement of neurological symptoms. Clinical neurophysiology revealed the presence of conduction block, absence of F waves, and in two cases a significant decrease in amplitude of compound motor action potential compound muscle action potential (cMAP). Four patients presented a mild facial nerve involvement limited to the muscles of the lower face, with sparing of the forehead muscles associated to ageusia. In one patient, taste assessment showed right‐sided ageusia of the tongue, ipsilateral to the mild facial palsy. In three patients we observed albuminocytological dissociation in the cerebrospinal fluid, and notably, we found an increase of inflammatory mediators such as the interleukin‐8. Peripheral nervous system involvement after infection with COVID‐19 is possible and may include several signs that may be successfully treated with immunoglobulin therapy.

Peripheral facial nerve palsy associated with COVID-19

“…Most patients in this study had isolated facial palsy with mild or moderate dysfunction and no other neurological findings. Except for the two described above by Goh and Casas (Casas et al 2020;Goh et al 2020), in all other studies, facial paralysis in COVID-19 patients occurred unilaterally or bilaterally in association with other manifestations of Guillain-Barré syndrome (Manganotti et al 2020;Ottaviani et al 2020;Juliao Caamaño and Alonso Beato 2020;Paybast et al 2020;Sancho-Saldaña et al 2020;Bigaut et al 2020).…”

Guillain–Barré syndrome spectrum associated with COVID-19: an up-to-date systematic review of 73 cases

“…All cases with available therapy data ( n = 70) except ten [ 13 , 15 , 23 , 25 , 26 , 33 , 35 – 37 , 41 ] were treated with intravenous immunoglobulin (IVIG) (Table 1 ). Conversely, plasma exchange and steroid therapy were performed in ten (four of them received also IVIG) and two cases, respectively.…”

“…Persistence of LL areflexia and distal paraesthesia Lascano et al [ 31 ] RT-PCR + chest X-ray WBC 4000 cells/mm 3 ; lymphocytes 600 cells/mm 3 ; PC 322,000 cells/mm 3 NA Increased total protein (140 mg/dL), cell count: 4 cells/μL, negative SARS-CoV-2 PCR Demyelinating with sural sparing pattern AIDP Brain: no pathological findings Spinal cord: lumbosacral nerve root enhancement IVIG 400 mg/kg (5 days) Amoxicillin Improvement of tetraparesis and ability to walk with assistance. Persistence of neuropathic pain and distal paraesthesia Manganotti et al [ 32 ] RT-PCR + chest CT NA Negative anti-ganglioside antibodies negative serum anti-HIV, anti-HBV, anti-HCV antibodies Increased total protein (74.9 mg/dL), negative CSF PCR for bacteria, fungi, Mycobacterium tuberculosis , Herpes viruses, Enteroviruses, Japanese B virus and Dengue viruses NA Brain: no pathological findings IVIG 400 mg/kg (5 days) Lopinavir/ritonavir, hydroxychloroquine, antibiotic therapy, oxygen support (35%) Resolution of all symptoms except for minor hyporeflexia at the LL Manganotti et al [ 33 ] RT-PCR IL-1: 0.2 pg/ml (< 0.001 pg/ml), IL-6: 113.0 pg/ml (0.8–6.4 pg/ml), IL-8: 20.0 pg/ml (6.7–16.2 pg/ml), TNF-α: 16.0 pg/ml (7.8–12.2 pg/ml) Negative anti-ganglioside antibodies, negative HIV, HBV, HCV negative serological tests for autoimmune disorders Increased total protein (52 mg/dl), leucocytes: 1 cell/mm 3 , negative SARS-CoV-2 PCR Demyelinating AIDP NA IVIG 400 mg/kg/day (5 days) Hydroxychloroquine, oseltamivir, darunavir, methylprednisolone and tocilizumab + mechanical invasive ventilation Improvement of motor symptoms Manganotti et al [ 33 ] RT-PCR IL-1: 0.5 pg/ml (< 0.001 pg/ml), IL-6: 9.8 pg/ml (0.8–6.4 pg/ml), IL-8: 55.0 pg/ml (6.7–16.2 pg/ml), TNF- α: 16.0 pg/ml (7.8–12.2 pg/ml) Negativ...…”

“…Autonomic disturbances were rarely reported (16.7%, 12/72). In cases with MFS/MFS-GBS overlap, areflexia, oculomotor disturbances, and ataxia were present in 100% (9/9), 66.7% (6/9) and 66.7% (6/9), respectively [8,19,23,30,32,33,43,44]. The median of time to nadir was calculated in 40 patients with available data and resulted 4 days (IQR 3-9) ( Table 1).…”

An Assessment of the Novel COVISTRESS Questionnaire: COVID-19 Impact on Physical Activity, Sedentary Action and Psychological Emotion

“…In Scotland, the financial impact of COVID-19 has been supported by the Scottish Government with a goal to protect and secure their world-leading research programmes through the provision of a £75 million one-off increase in funding for Scotland’s universities [ 10 ]. More recently, various independent and collaborative multidisciplinary related research studies on COVID-19 have been investigated in the area of equipment and manufacturing [ 11 , 12 , 13 , 14 ], pathophysiology [ 15 , 16 , 17 ], neurophysiology [ 18 , 19 , 20 , 21 ], radiology [ 22 , 23 , 24 , 25 ], psychology [ 26 , 27 ], diagnostics [ 28 , 29 , 30 , 31 , 32 ] and treatment [ 33 , 34 , 35 ].…”