Guillain–Barré Syndrome Associated with SARS-CoV-2

Abstract

To the Editor: From February 28 through March 21, 2020, in three hospitals in northern Italy, we examined five patients who had Guillain-Barré syndrome after the onset of coronavirus disease 2019 , the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During that period, an estimated 1000 to 1200 patients with Covid-19 were admitted to these hospitals. Four of the patients in this series had a positive nasopharyngeal swab for SARS-CoV-2 at the onset of the neurologic syndrome, and one had a negative nasopharyngeal swab and negative bronchoalveolar lavage but subsequently had a positive serologic test for the virus. Detailed case reports are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.The first symptoms of Guillain-Barré syndrome were lower-limb weakness and paresthesia in four patients and facial diplegia followed by ataxia and paresthesia in one patient (Table 1). Generalized, flaccid tetraparesis or tetraplegia evolved over a period of 36 hours to 4 days in four patients; three received mechanical ventilation. The interval between the onset of symptoms of Covid-19 and the first symptoms of Guillain-Barré syndrome ranged from 5 to 10 days (Table 1 and Fig. S1 in the Supplementary Appendix). None of the patients had dysautonomic features.On analysis of the cerebrospinal fluid (CSF), two patients had a normal protein level and all the patients had a white-cell count of less than 5 per cubic millimeter. Antiganglioside antibodies were absent in the three patients who were tested. In all the patients, a real-time polymerase-chain-reaction assay of the CSF was negative for SARS-CoV-2. Results of electrophysiological studies are shown in Table S1. Compound muscle action potential amplitudes were low but could be obtained; two patients had prolonged motor distal latencies. On electromyography, fibrillation potentials were pres-* Covid-19 denotes coronavirus disease 2019, CSF cerebrospinal fluid, ICU intensive care unit, IVIG intravenous immune globulin, MRI magnetic resonance imaging, PCR polymerase chain reaction, and SARS-CoV-2 severe acute respiratory syndrome coronavirus 2. † On CSF analysis, all the patients had a normal glucose level and IgG index and a polyclonal pattern on electrophoresis. The normal range for the protein level is 15 to 45 mg per deciliter. ‡ An enzyme-linked immunosorbent assay was used to test for antibodies to GM1, GQ1b, and GD1b.

Integrated analyses of single-cell atlases reveal age, gender, and smoking status associations with cell type-specific expression of mediators of SARS-CoV-2 viral entry and highlights inflammatory programs in putative target cells

“…Taken together, the expression of myelin proteins across multiple ACE2 + TMPRSS2 + cells may hypothetically contribute to antigen presentation and autoimmune response in the context of viral infection. A small number of COVID-19 patients were reported to have Guillain-Barre Syndrome 144 , with a demyelinating process in some; this is consistent with observations of Guillain-Barre Syndrome following other viral infections such as Zika, influenza, and Epstein-Barr virus 139,145,146 . Whether anti myelin specific immunity can be induced by virus infected cells expressing myelin proteins remains an area for future study.…”

Guillain‐Barré syndrome during SARS‐CoV‐2 pandemic: A case report and review of recent literature

“…reported. [4][5][6][7][8] All patients had fever and respiratory symptoms 5 to 10 days before the onset of the neurological symptoms, one of them had ongoing fever and poor general condition. The electrodiagnostic findings were consistent with an axonal variant of GBS in four out of nine patients.…”

“…3 A few patients with demyelinating and axonal type of Guillain-Barré syndrome have been reported recently, the onset of neurological symptoms occurred 5 to 10 days after the diagnosis of COVID-19 with respiratory symptoms. 4 tions, which is often fatal for patients with COVID-19. 1,2,4,5 It is likely, that these immunological processes are responsible for the major part of the organ manifestations, including the neurological complications.…”

“…4 tions, which is often fatal for patients with COVID-19. 1,2,4,5 It is likely, that these immunological processes are responsible for the major part of the organ manifestations, including the neurological complications.…”

Autoimmune haemolytic anaemia associated with COVID‐19 infection

“…2 However, the spectrum of complications is broader and includes among others various auto-immune disorders such as autoimmune thrombocytopenia, Guillain-Barr e and antiphospholipid syndrome. [3][4][5] In this report we describe seven patients from six French and Belgian Hospitals who developed a first episode of autoimmune haemolytic anaemia (AIHA) during a COVID-19 infection.…”