|Ahead of print
Association of Guillain-Barre Syndrome and SARS COV 2 infection in a child: First case report from india
Deepak Kumar1, Garima Gupta2, Urmila Jhamb1
1 Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
2 Department of Pediatrics, ESI Hospital, Rohini, New Delhi, India
|Date of Submission||18-Sep-2020|
|Date of Decision||14-Jan-2021|
|Date of Acceptance||24-Mar-2021|
|Date of Web Publication||07-Jan-2022|
Department of Pediatrics, Maulana Azad Medical College, 110002.
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Association of Guillain-Barre Syndrome (GBS) with SARS COV 2 infection has been found often in adults and elderly patients. However, this manifestation is rarely noted in children, only three pediatric patients have been reported in the literature globally. In this report, we describe an 8-year-old child who was admitted with an acute onset symmetrical quadriparesis. He had a history of SARI (fever, cough, and vomiting) 20 days prior to the admission. He was confirmed GBS by clinical assessment, CSF albuminocytological dissociation, and nerve conduction study. SARS COV 2 infectivity was confirmed by RTPCR in both child and mother. The course of the illness strongly suggests an association between the GBS and SARS COV 2 infection in this case.
Keywords: Association, COVID, Guillain-Barre syndrome, SARS COV 2
| Introduction|| |
COVID-19 disease has infected 29 million cases and caused over 930 thousand deaths globally. The causative agent named SARS-COV 2 virus, primarily affects the respiratory system, it manifests variably from mild flu like illness to severe pneumonia and acute respiratory distress syndrome (ARDS). Extra-pulmonary manifestations among COVID-19 patients have been growingly reported in the literature. The involvement of the neurological system, both central and peripheral, has been seen with SARS COV 2 infection though less frequently than the gastrointestinal, cardiovascular, and hepato-renal system. The onset of the Guillain-Barre syndrome (GBS) post exposure of SARS COV 2 infection has been discerned in various reports, predominantly among elderly and adults. In contrast, this association is very rarely noted in children. We are reporting this case, first from India, describing the association between GBS and SARS COV 2 infection in a young child.
| Case|| |
An 8-year-old male child was admitted to our facility, the largest COVID hospital in northern India. He had complaints of rapidly progressive weakness in all four limbs. The symptoms started 3 days back, with the perception of pain in the lower limbs on day 1. The next morning, the child developed weakness in the lower limbs noted as difficulty in walking and swinging gait. Weakness had rapidly progressed and involved the upper limbs for which the child was taken to the nearby non-COVID hospital. He was clinically diagnosed GBS and was immediately started IVIG at the dose of 1 mg/kg infused over next 48 h. He had a history of fever, mild cough, and vomiting 20 days prior to the admission which resolved after 5 days of oral medications, also her mother had developed fever and cough 15 days back. With this history, the suspicion of COVID infection was kept and both were tested positive for SARS COV 2 infection (on 20-08-2020) using the RTPCR method of detection. The patient along with his mother was transferred to COVID hospital.
The child was admitted in the pediatric ICU. On neurological examination, the patient had normal consciousness, language, and there were no signs of cranial nerve deficit. Symmetric flaccid quadriparesis was found (Medical Research Council scale, power- 2/5 in both upper limbs and 1/5 in both lower limbs), respiratory muscles were not involved, deep tendon reflexes were absent, and there was no plantar response. Perception of fine touch and vibration was preserved in both upper and lower limbs. Bowel and bladder were found intact.
Blood analysis showed hemoglobin of 12.2 gm/dL, TLC- 6300 cu mm, and platelet counts- 247 × 103. LFT, KFT, D Dimer, IL-6, and procalcitonin levels were normal. CSF analysis was done: Sugar was 75 mg/dL, protein content was high- 200 mg/dL, and a total of 2 lymphocytes per cu mm were found on the microscopic examination.
The patient was kept in the pediatric ICU for monitoring, improvement in power of upper limbs was observed and the child was shifted to the general ward. On day 14 of the admission, both child and mother were tested negative for SARS COV 2 and were discharged [Figure 1]. NCV was performed, motor nerve conduction study showed absent muscle nerve action potentials in bilateral tibial, peroneal, and ulnar nerve, F-waves were absent, and delayed latencies were observed in the bilateral median nerve. Sensory nerve conduction was preserved in all nerves tested. These findings were consistent with acute motor axonal (AMAN) type of polyneuropathy.
| Discussion|| |
SARS COV 2 is primarily a pneumotropic virus with diverse respiratory symptoms manifesting as mild flu like illness to severe pneumonia and acute respiratory distress syndrome (ARDS). Also, gastrointestinal, cardiovascular, hepatorenal, cutaneous and nervous system involvement in COVID disease have been seen in several reports. In a review done by Mao et al., common CNS symptoms observed in the SARS COV 2 infected patients were headache, dizziness, altered consciousness, and stroke. Involvement of peripheral nervous system exhibited hyposmia/anosmia, polyneuropathy, and/or neuralgia. Rarely, encephalitis and meningitis have also been described. The neurotropic mechanism of SARS COV 2 virus is not well known, it is thought that the CNS manifestation could be due to direct invasion via olfactory bulb or cranial nerves, hematogenous spread, secondary to a hypercoagulable state, and/or dysregulated immune response.
There are emerging evidence showing an association between GBS and SARS COV 2 infection. However, the mean age of presentation was 55 years and the mean duration between onset of GBS symptoms and respiratory symptoms was 7.5 days (5–10 days) observed in a review done by Abu et al. on 73 patients. To the best of our knowledge, only three cases have been documented in the pediatric population worldwide, each from Saudi, Brazil, and Iran. All the cases had typical neurological features and CSF albumin cytological dissociation, electrophysiological study was performed in two cases only. First case was an 11-year-old boy, NCV study showed delayed latencies, low amplitude action potential, and absent F waves consistent with demyelinating polyneuropathy. Second case was a 15-year-old girl, NCV study revealed reduction of action potential and absent F waves in all motor nerves, sensory nerve conduction was intact suggestive of acute motor axonal type of neuropathy. Third case was a 13-year-old female, consent to perform NCV study was not given in this case.
The GBS is an immune-mediated polyradiculoneuropathy which is a post-infectious response. Interval of at least 3–4 weeks is classically described between the infection exposure and the onset of GBS; however, the virus is new and its neuro-invasive characteristics are not well understood. Also, it has been noted that the disease response in children is invariably different from the adults infected with SARS COV 2. Our case was confirmed as suffering from GBS by the diagnostic triad of clinical assessment, CSF albumin-cytological disassociation, and NCV. We have described the first pediatric case from India having a definite association between GBS and SARS COV 2 infection in this report.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. WHO coronavirus disease (COVID-19) dashboard. Geneva: World Health Organization; 2020. Available from: https://covid19.who.int/ [Last accessed on 2020 Sep 16].
Johnson KD, Harris C, Cain JK, Hummer C, Goyal H, Perisetti A. Pulmonary and extra-pulmonary clinical manifestations of COVID-19. Front Med (Lausanne) 2020;7:526. doi: 10.3389/fmed.2020.00526
Abu-Rumeileh S, Abdelhak A, Foschi M, Tumani H, Otto M. Guillain–Barré syndrome spectrum associated with COVID-19: an up-to-date systematic review of 73 cases. J Neurol2020. https://doi.org/10.1007/s00415-020-10124-x
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al
. Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol 2020;77:683-90.
Moriguchi T, Harii N, Goto J, Harada D, Sugawara H, Takamino J, et al
. A first case of meningitis/encephalitis associated with SARS-coronavirus-2. Int J Infect Dis 2020;94:55-8.
Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kummerlen C, et al
. Neurologic features in severe SARS-cov-2 infection. N Engl J Med 2020;382:2268-70. 10.1056/NEJMc2008597
Khalifa M, Zakaria F, Ragab Y, Saad A, Bamaga A, Emad Y, et al
. Guillain-Barré syndrome associated with severe acute respiratory syndrome coronavirus 2 detection and coronavirus disease 2019 in a child. J Pediatr Infect Dis Soc, piaa086. https://doi.org/10.1093/jpids/piaa086
Frank CHM, Almeida TVR, Marques EA, Monteiro QS, Feitoza PVS, Borba MGS, et al
. Guillain-Barré syndrome associated with SARS-CoV-2 infection in a pediatric patient. J Trop Pediatr 2020. https://doi.org/10.1093/tropej/fmaa044
Mozhdehipanah H, Paybast S, Gorji R. Guillain-Barré syndrome as a neurological complication of COVID-19 infection: a case series and review of the literature. Int Clin Neurosci J 2020;7:156-61.