Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

Guillain-Barre syndrome associated with SARS-CoV-2 infection: A case series from 4 Colombian cities during the pandemic

SARS-CoV-2 infection has been associated with multiple neurological manifestations. One such manifestation, which has been described since the early stages of the COVID-19 pandemic and is relevant for current neurological practice, is Guillain-Barre syndrome (GBS). The literature describes neurotoxic mechanisms of the virus itself and the possible pathways by which it may affect the peripheral nerves in experimental studies;however, we still lack information on the mechanisms causing the immune response that gives rise to GBS in the context of SARS-CoV-2 infection. Colombia is one of the Latin American countries worst affected by the pandemic, with the third-highest number of cases in the region;thus, it is essential to recognise GBS, as this potential postinfectious complication may severely compromise the patient's functional status in the absence of timely diagnosis and treatment. We present a series of 12 cases of GBS associated with SARS-CoV-2 infection from hospitals in 4 different Colombian cities and describe the clinical presentation, laboratory and electrophysiological study findings, and treatment.Copyright © 2022 Sociedad Espanola de Neurologia

AZD1222 (ChAdOx1 nCoV-19) Vaccine: Hurdles and Visions

ChAdOx1 nCoV-19 (AZD1222) is a replication-deficient chimpanzee adenovirus vectored vaccine developed by Oxford and AstraZeneca for a disease we all know as Coronavirus, or COVID-19. Ongoing clinical studies reveal that the ChAdOx1 nCoV-19 vaccine has a tolerable safety profile and is effective against symptomatic COVID-19. This vaccine may prove crucial in boosting herd immunity, averting life threatening illness, and relieving the current pandemic. In this mini review, we performed a thorough literature search through PubMed and Google Scholar and reported various case reports associated with complications of the adenovirus-vectored COVID-19 vaccine. Various adverse effects of the ChAdOx1 nCoV-19 vaccine were reported around the globe, which were often serious but rare and developed into life-threatening pathologies such as GBS, thrombocytopenia, demyelinating neuropathies, progressive dementia, cerebral infarction, IgA vasculitis, hemophagocytic lymphohistiocytosis, herpes zoster, cutaneous reactions, and vein thrombosis. These worldwide reported complications, which are usually rare and severe, will aid clinicians in understanding and managing unforeseen situations. There is a need for more research to find out more about these complications and their etiopathogenesis. However, the benefits of these vaccinations for stopping the spread of the outbreak and lowering the fatality rate outweigh the potential risk of the uncommon complications.Copyright © The Author(s) 2023.

TH-261. A case of GBS-like polyneuropathy with unusual progression (Case Report)

Nodal and paranodal antibody-associated neuropathies have been recently classified as auto-immune nodopathies. Their clinical presentation can be easily mistaken for acute or chronic idiopathic demyelinating polyneuropathy (AIDP/CIDP). We present a case of pan-neurofascin antibody associated paranodal neuropathy with serial electrodiagnostic findings. A 61-year-old man presented with acute onset generalized weakness and tiredness one day after the Covid-19 booster vaccination. He had progressive sensory disturbance and weakness in his upper limbs spreading to the lower limbs. He was treated with IVIg for Guillain-Barre syndrome (GBS) and discharged with some improvement. Five days later, he developed rapidly progressive predominantly motor symptoms becoming quadriplegic and bedbound within 9 days with no cranial or respiratory involvement. He was found to have paranodal antibodies (neurofascin-155), consistent with a pan-neurofascin antibody positive neuropathy. Although the patient responded poorly to conventional immunomodulatory therapies, he showed a rapid remarkable recovery with rituximab. He was able to walk independently again within 3 weeks after the second dose of rituximab. Electrodiagnostic studies showed only subtle proximal demyelinating features with the initial presentation. The repeat study after his relapse showed a significant deterioration with features of a generalized, non-length-dependent, primarily demyelinating, sensorimotor polyneuropathy with conduction block, but the sural nerve biopsy showed axonal neuropathy. Electrodiagnostic findings nearly normalized two months after rituximab treatment with the resolution of the all the demyelinating features. This case presentation highlights the importance of considering nodal/paranodal neuropathy as a differential for AIDP/CIDP in an early stage of the disease, especially in patients with atypical presentation. In addition, it supports the currently available evidence that more targeted treatment such as rituximab can have an excellent outcome. Copyright © 2022

TH-126. Preliminary results of an Andalucia-South of Spain multicentric registry of SARS-CoV-2 postvaccination neuromuscular pathology

Introduction: European Medicines Agency (EMA) approved SARS-Cov-2 vaccines that are administered in Andalucia, south of Spain, have a very good clinical efficacy against Covid-19 and safety profile. Secondary effects (SE) associated with these vaccines are mainly mild (arthralgias myalgias), being SE related with the nervous system infrequent (>1/1000 to <1/100) tremor, paraesthesia, dizziness;rare (>=1/10.000 to < 1/1000) peripheral facial palsy, or very rare (<1/10.000) Guillain Barre syndrome (GBS). 85% of the Andalusian population have been already fully vaccinated, so our environment constitutes an ideal observatory for the real-life analysis of possible neuromuscular SE related to this vaccine. Result(s): Multicentric retrospective observational study of postvaccination against SARS-Cov-2 neuromuscular SE. We actively searched in 10 Andalusian hospitals for objective SE referred for electroneurography (ENG) and/or electromyography (EMG) after SARS-Cov-2 vaccination. We have registered 21 patients (12 males/9 females): 4 acute demyelinating polyneuropathies GBS;2 brachial plexopathies (Parsonage Turner type);1 ipsilateral of vaccine injection and one contralateral;1 inferior limb proximal myopathy in the context of a myocarditis;and 1 presented an acute neuromuscular postsynaptic defect Miastenia Gravis;the rest of the patients had distal paraesthesia with normal ENG-EMG. Conclusion(s): Neurophysiological studies in patients with peripheral neurological symptoms after SARS-Cov-2 vaccination are generally normal, but we should keep alert for possible serious and treatable complications that can be diagnosed with ENG-EMG tests. It would be advisable to extend this multicentric study the get a real idea of the performance of SARS-Cov-2 postvaccine ENG-EMG tests. Copyright © 2022

Guillain-Barre Syndrome with Lethal Outcome Following COVID-19 Vaccination-Case Report Supported by Autopsy Examination

Objective: After the outbreak of the global pandemic caused by SARS-CoV-2 infection at the end of the year 2019, it took one year to start vaccinatioagainst this infection with products from various manufacturers. As of November 2021, more than 8 billion vaccine doses against COVID-19 havbeen administered, which is essentially linked to a spike in adverse events reports following these vaccinations, including a number of neurologicaadverse events. Case Report: We report a case of a 71-year-old patient with lethal fulminant onset of Guillain-Barre syndrome after the second dose of mRNA vaccintozinameran. This is, to our best knowledge, the first case report of this adverse event supported by autopsy and histological examination. Thpatient presented with progressive ascending weakness and paresthesia, with typical cytoalbuminologic dissociation in cerebrospinal fluid ansevere motoric and sensitive axonal-demyelinating polyneuropathy on electromyography. The patient's history and complex diagnostic workup dinot reveal any other possible causative factors. The patient did not respond to the treatment with intravenous immunoglobulins and died 10 daylater due to aspiration bronchopneumonia as a complication of respiratory muscles paralysis. Conclusion(s): Most of the reported adverse reactions following COVID-19 vaccination include mild or moderate events noticed in the post-vaccination periodhowever, reports of possible lethal outcomes are no exception. Still, the overall incidence of GBS after vaccination does not significantly exceed itincidence in the general population. Each such report should be carefully examined by a team of specialists to prevent overestimation of lethaadverse events linked to vaccinations, especially in fatalities that happen in the post-vaccination period. Copyright © 2022 Mosna et al.

COVID-19-Related Neuropathy in Colombia: The Experience During the First 23 Months of Pandemic

COVID-19-related neuropathy in Colombia: The experience during the first 23 months of pandemic Introduction: The SARS-CoV-2 virus has a high neuroinvasive capacity due to the increased expression of angiotensin-converting enzyme receptor 2 (ACE-2) in neurons (1) and it is believed that the mechanism by which it can cause injury to the nervous system peripheral nervous system is immunemediated, although a direct cytotoxic effect of the virus cannot be ruled out (2). Multiple types of neuropathy associated with SARS-CoV-2 infection have been described, the most frequent being Guillain- Barré syndrome, pre-existing diabetes, compression neuropathies and drugs used to treat symptoms of COVID-19 (3). Objetives: To characterize the patients who were referred to the electromyography laboratory at the Fundacion Santa Fé de Bogotá, Colombia due to suspected COVID-19-related neuropathy Methods: Descriptive observational study, case series type. The electrodiagnostic studies carried out between January 2020 and December 2022 in the electromyography laboratory at the Fundacion Santa Fé de Bogotá, Colombia with suspected COVID- 19-related neuropathy were reviewed. Results: 94 patients were evaluated in the electromyography laboratory with suspected COVID 19-related neuropathy between January 2020 and December 2021, of which 53% (50/94) were men. The average age was 54.8 years. 32% (30/94) had severe COVID and 31% (29/94) were hospitalized in the ICU. Most of the studies were normal: 35% (33/94). of the abnormal findings, it was found in order of frequency: Symmetric motor and sensory axonal polyneuropathy in 21.2%, and of this group of patients, 55% were in the ICU, 35% had no data and 20% were hospitalized-not ICU. 18% presented compression neuropathy of the median nerve in the carpal tunnel, 6.3% asymmetric motor and sensory axonal neuropathy, 6.3% suggestive findings of cervical and/or lumbosacral root involvement, 4.2% Guillain Barré syndrome, 4.2% compression neuropathy of the peroneal nerve , 2.1% brachial plexus axonal injury, 2.1% peroneal nerve axonal injury, 2.1% radial axonal injury, 2.1% myopathic changes, 1% hypoglossal nerve axonal injury, 1% symmetric axonal and demyelinating polyneuropathy, 1% hereditary neuropathy, 1% asymmetric demyelinating neuropathy, 1% axonal injury of the sciatic nerve, 1% axonal injury of the median nerve in the forearm, 1% axonal injury of the lumbosacral plexus, 1% compression neuropathy of the ulnar nerve in the elbow and 1% axonal injury from a sensory branch of the median nerve. Conclusions: The most frequent abnormality in the study was symmetric motor and sensory axonal polyneuropathy, which can be explained by the prolonged ICU stay, which increases the risk of Critical illnes Neuropathy.

Guillain-Barré Syndrome After Receiving the First Dose of Oxford– AstraZeneca SARS-CoV-2 Vaccine

Safety monitoring of COVID-19 vaccination is paramount of importance. There are limited reports of Guillain-Barré syndrome (GBS) associated with the COVID-19 vaccination. The present study reported a case of GBS following the first dose of the Oxford-AstraZeneca SARS-CoV-2 vaccine. A 32-year-old man presented a history of progressive descending weakness and autonomic features within a month after receiving the Oxford-AstraZeneca SARS-CoV-2 vaccine. The neurological examination was consistent with acute polyneuropathy. The para-clinical investigations were in favor of acute demyelinating polyneuropathy. The patient was diagnosed with GBS, and IVIG was initiated as an acute treatment, which led to significant clinical recovery. We reported a case of GBS after receiving the Oxford-AstraZeneca vaccine. However, our findings dose not conclude a causal association between GBS and COVID-19 vaccination.

A RARE CASE of ACUTE INFLAMMATORY DEMYELINATING POLYRADICULOPATHY FOLLOWING the SECOND DOSE of PFIZER COVID-19 VACCINE

Background: We present a case of a 36 year-old female who developed Acute Immune-mediated Demyelinating Polyneuropathy (AIDP) after receiving the second dose of Pfzer COVID-19 vaccine. Objectives: To report a rare auto-immune complication of COIVD-19 vaccination. To educate and inform physicians about the approach to diagnosing AIDP and narrowing down its etiology. Methods: Case report and literature review Results: A 36 year-old female with no signifcant past medical history presented to the hospital with progressive bilateral paresthesia. She started to experience numbness and tingling sensation in her extremities 1 week after receiving the second dose of Pfzer COVID-19 vaccine. Following 5 days of symptoms onset, she was no longer able to hold onto objects and experienced difficulty ambulating without assistance. Physical exam was notable for decreased distal sensation to touch and pain in all 4 limbs, otherwise, the rest of her neurological and musculoskeletal evaluation was normal. MRI-head showed small scattered foci of increased FLAIR signal in the white matter, suggesting an underlying infammatory process. Electromyography (EMG) was performed and showed evidence of acute diffuse sensorimotor neuropathy with mixed axonal and demyelinating features. These results along with the clinical features allowed us to diagnose our patient with Acute Immune-mediated Demyelinating Polyneuropathy (AIDP). Extensive autoimmune workup, including anti-GM1, GD1b, Gq1b, ANA, DS-DNA, RF, CCP, and C/P ANCA, were unremarkable. She had positive anti-Ro atb but did not have any clinical or physical features that would suggest Sjogren's Syndrome. Vitamin levels (B12, folate, thiamine) were found to be normal. Infectious workup of serum and CSF which included hepatitis serologies, Campylobacter jejuni serology, Lyme atb, CMV atb, EBV atb were all negative. The possible etiology of her disease was attributed to Pfzer COVID-19 vaccine given the temporal correlation. She was subsequently treated with 6 cycles of IVIG which resulted in moderate symptomatic improvement. Conclusion: AIDP is an autoimmune-guided infammatory neuropathy which result in axonal degeneration of myelinated nerves [1]. In some extremely rare cases, molecular mimicry following vaccination may lead to this disease [1]. There have been reports of AIDP linked to Johnson & Johnson and AstraZeneca COVID-19 vaccines [2]. Recently, a few cases have also been observed with Pfzer COVID-19 vaccine [2-3]. Interestingly, the majority of these cases occurred after the frst dose of the vaccine, making our case even more peculiar [2]. We report this case as physicians should be made aware that AIDP is a potential complication of COVID-19 vaccination. Given the extreme rarity of these cases, it is also important to note that more common infectious and autoimmune etiology of AIDP should be investigated before attributing any potential causal relationship to COVID-19 vaccines.

Combined central and peripheral demyelination syndrome after COVID-19 vaccination with brisk response to plasma exchange and steroids

Objective: - Report a case of combined central and peripheral combined demyelination (CCPD) syndrome after COVID19 vaccine with brick improvement to steroids and PLEX - Provide a brief literature review of CCPD etiology and management Background: Combined central and peripheral demyelination (CCPD) is a rare, immunemediated disorder that presents with concurrent demyelination in the central and peripheral nervous system. Known clinical course and radiologic/electrodiagnostic features stem only from a limited number of case reports and small case series. The disease course can be monophasic or chronic. Response to immunomodulatory treatment is variable. Design/Methods: N/A Results: 59-year-old female presented with progressive lower extremity pain, weakness and urinary incontinence four weeks after receiving her second COVID-19 vaccine. Exam was notable for mild somnolence, restricted lateral gaze, right eye red desaturation without APD, ocular ataxia, left lower facial weakness, and lower extremity paresis with decreased reflexes. MRI of the brain and spinal cord showed multifocal supratentorial, intratentorial, cervical and thoracic cord white matter signal abnormalities with trace enhancement in combination with marked cauda equina enhancement. CSF showed albuminocytologic dissociation (protein of 184 and 2 nucleated cells). NMO, Anti-MOG and neurofascin-155 antibodies were negative. Electromyelogram and nerve conduction studies were consistent with a demyelinating polyneuropathy. The patient was treated with a 1 gram IV methylprednisolone daily and five treatments of plasma exchange. At six months, the patient had nearly returned to her previous baseline. Conclusions: CCPD is a rare inflammatory neurologic condition of peripheral and central demyelination. The etiology remains unclear, though viral infections and immunizations have been reported to proceed CCPD in some patients. Limited data is available to guide treatment but PLEX, IVIG and steroids are the most common. Outcomes are heterogeneous and methods to predict long term course remains uncertain. To our knowledge, this is the first reported case of CCPD after the COVID 19 vaccine.

A rare case of bilateral Bell' s Palsy in the setting of SARS-CoV-2

Objective: To describe a rare case of an AIDP variant with bilateral bell's palsy in the setting of SARS-CoV-2. Background: Bilateral facial paralysis is a rare clinical presentation, usually in the setting of underlying systemic disease. Bilateral Bell 's palsy is defined as facial paresis or paralysis involving both sides of the face with an onset that is either simultaneous or within 30 days of each other and represents less than 2% of all facial palsies. AIDP is a potential cause of bilateral facial palsy, and is prevalent in 24-60% of cases. We report a case of a 62-year-old female who presented with bilateral Bell's palsy with bilateral lower extremity weakness and recently positive for SARS-CoV-2. Patient had appropriate findings to suggest a form of acute inflammatory demyelinating polyneuropathy (AIDP), however hyperreflexia on the exam creates a case of a plausible variant such as Acute Motor Axonal Neuropathy (AMAN). Design/Methods: Case report and literature review. Literature review spanning 2009-2021 was conducted via Pubmed. Search terms were “COVID-19”, “bilateral Bell's Palsy”, “facial diplegia”, “Guillain Barré Syndrome”, “AIDP”, “hyperreflexia” Results: Literature review found 9 nerve conduction studies confirming AIDP cases with bilateral Bell's palsy and SARS-CoV-2. 17 non-SARS-CoV-2 cases were found to have AIDP with hyperreflexia, however nerve conduction studies found an axonal neuropathy, suggesting the diagnosis of AMAN. Since this patient presented with hyperreflexia, AMAN, which is a rare AIDP subtype, could have been a likely diagnosis. Conclusions: SARS-CoV-2 infection has been associated with several neurological manifestations. AIDP, in particular, has increased in incidence with the rise in SARS-CoV-2 infections via unclear immune mediated mechanisms. The patient's bilateral Bell's palsy indicates a rare AIDP variant. Interestingly, this patient had upper motor neuron signs, but with nerve conduction studies consistent with distal demyelinating neuropathy without denervation/motor axonal loss.

A Case of ChronicInflammatory Demyelinating Polyneuropathy after Pfizer COVID-19 Vaccination

Objective: NA Background: Chronic inflammatory demyelinating polyneuropathy is an immune-mediated polyneuropathy characterized by peripheral demyelination, resulting in symmetrical sensory loss and distal and proximal muscle weakness. While CIDP has been reported after influenza, tetanus, and other common vaccinations, this is the first reported case of CIDP after Pfizer COVID-19 vaccination to our knowledge. Design/Methods: NA Case Presentation: A 34-year-old right-handed male with an unremarkable past medical history presented with bilateral distal paresthesias, proximal and distal muscle weakness, and fine motor difficulties. Symptoms initially manifested with toe numbness, approximately two weeks after receiving the first dose of the Pfizer COVID-19 vaccine. Paresthesias gradually progressed from lower extremities to upper extremities. Two months after the initial COVID-19 vaccine, symptoms worsened with decreased muscle strength, difficulties with fine motor activities, difficulties climbing stairs, and lifting objects above his head. Neurologic evaluation revealed 4/5 strength in upper and lower extremities, generalized hyporeflexia, decreased vibration, and proprioception. MRI of the brain and spine revealed no abnormalities. Nerve conduction studies were consistent with demyelination and cerebral spinal fluid analysis revealed albuminocytologic dissociation. The patient was diagnosed with CIDP and began steroids after poor response to a four-day treatment course of IVIG 2g/kg which resulted in partial improvement of strength. The patient continues to follow up with long-term prednisone therapy. Conclusions: Demyelinating polyneuropathies are a rare complication of vaccination. While the benefits outweigh the risks of immunization, we aim to inform of this potential complication.

Acute and Chronic Demyelinating Neuropathies following COVID-19 Vaccination: A Report of Four Cases

Objective: To report demyelinating neuropathies following COVID-19 vaccination. Background: Suspected COVID-19 vaccine-associated Guillain-Barre syndrome and other demyelinating conditions affecting the peripheral nervous system have been reported. The pathophysiologic basis of these associations, and that of vaccination-associated demyelinating neuropathies in general, has not been established. Design/Methods: Case report Results: Four cases of acute and chronic demyelinating neuropathies following COVID-19 vaccination were seen at the University of Nebraska Medical Center from May to September 2021. All were males, ages 26-83 years old. Two received the Pfizer-BioNTech vaccine, one Moderna, and one Johnson&Johnson. Onset ranged from 2-21 days after the final dose of vaccination. The time from symptom onset to neurological evaluation ranged from 3 weeks to 4 months, during which symptoms progressed. All cases presented with progressive numbness, weakness, and areflexia in all limbs;two had difficulty walking. Severe facial diplegia was seen in two cases and other bulbar symptoms in one other case. Three cases had electrophysiologic studies confirming demyelination while one case had findings of subacute polyradiculopathies. Cerebrospinal fluid protein was elevated in two cases and normal in the others. No cases had other co-morbidities or histories suggesting an alternate diagnosis. The diagnosis was acute inflammatory demyelinating polyneuropathy (AIDP) in one case, chronic demyelinating polyradiculoneuropathy (CIDP) in two, and subacute polyradiculopathies in one. The cases with AIDP and CIDP received treatment with intravenous immunoglobulin due to significant motor disability, while the case with subacute polyradiculopathies had spontaneous recovery within 8 weeks. Of the treated cases, two had significant improvement by outpatient follow-up at 2-4 weeks post-treatment and one has yet to follow up. Conclusions: Continued identification and reporting of demyelinating neuropathies following COVID-19 vaccination is essential to determine whether a causative association is present. Prompt evaluation for alternative etiologies is vital and early treatment is recommended.

Inflammatory demyelinating polyneuropathy after the ChAdOx1 nCoV-19 vaccine may follow a chronic course.

BACKGROUND: Rare autoimmune neurological events have been reported during the ongoing global drive for mass vaccination as a means of controlling the Covid-19 pandemic. Guillain-Barré syndrome, an acute inflammatory neuropathy well recognised as a rare complication of influenza vaccination, has been reported to follow administration of the ChAdOx1 nCoV-19 (AstraZeneca) vaccine. METHODS: We report four patients with inflammatory demyelinating polyneuropathy after vaccination in whom a relapsing or progressive course indicated the development of chronic inflammatory demyelinating polyneuropathy (CIDP). CONCLUSIONS: Awareness of this complication and distinction from Guillain-Barré syndrome enables the timely institution of maintenance immunomodulatory treatment. Our report also highlights the likely relationship between vaccination and the subsequent development of CIDP, but definitive demonstration of a causal link needs larger studies.

CoViD-19 infection presenting as Guillain Barr syndrome

Background: The Guillain Barr syndrome (GBS) has been linked with several viral infections including CoViD-19. Description of clinical cases: 5 out of 352 patients referring to Department of Medicine for CoViD-19 infection showed neurological symptoms suggesting GBS. All patients were confirmed as SARS-CoV-2 infected by PCR on nasopharyngeal swabs. Mean age was 63.4. One was female and 4 males. In 3 cases the infection was mild, no lung involvement was found and no intensive care was required. Intensive care admission was needed in a case with bilateral interstitial pneumonia and neurological symptoms and in a patient with pulmonary embolism. All patients suffered for diffuse, severe motor and sensory involvement. In 4 cases the ranking score at admission was 4, in one was 5. Neurophysiological investigations were performed in all patients. Two cases showed an acute inflammatory demyelinating neuropathy, in 3 cases an acute axonal neuropathy was observed. An increase in proteins was detected in cerebrospinal fluid. The presence of viral- RNA for SARS-CoV-2 in the CSF resulted negative as well as the antibodies against gangliosides. Two patients were treated with dexamethasone whereas in three patients immunoglobulins were added. Neurological symptoms gradually improved in all cases, in fact, the ranking score was 3 at hospital discharge. Conclusions: Five patients showed neurological symptoms suggesting GBS. These symptoms before treatment resulted severe and improved after therapy. Further studies are needed to confirm whether the CoViD-19 can induce the clinical development of GBS.

Motor demyelinating tibial neuropathy in COVID-19.

Ten patients suffering from residual symptoms after the resolution of COVID-19, which manifested as fatigue in the lower limbs, have been submitted to nerve conduction studies. Motor demyelinating neuropathy features mainly of the tibial nerves but also the peroneal, median, and ulnar nerves were objectified. These findings might be considered as new neurological characteristics of SARS-CoV-2 infection.

Chronic Inflammatory Demyelinating Polyradiculoneuropathy During the COVID-19 Pandemic: Telemedicine Limitations and Strategies for Improvement.

Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) is a relapsing-remitting or progressive inflammatory neuropathy, which can present in a multitude of phenotypes. It can be a challenging condition to diagnose and requires thorough clinical evaluation and electrodiagnostic testing. With the outbreak of coronavirus disease in 2019 (COVID-19), large portions of the medical field converted to telemedicine to facilitate patient visits. We report a case of a 50-year-old female who was seen via video visit during the COVID-19 pandemic who was later diagnosed with CIDP and treated with intravenous immunoglobulins with improvement in clinical examination and electrodiagnostic testing. This case highlights the limitations of performing the neuromuscular examination via telemedicine.

COVID-19 as a Trigger of Recurrent Guillain-Barré Syndrome.

Coronavirus 2019 (COVID-19) has been reported to trigger Guillain-Barré syndrome (GBS). While uncommon, recurrent GBS (rGBS) episodes, triggered by antecedent viral infections, have been reported in a small proportion of GBS patients, here we describe a patient with a recurrent case of GBS, occurring secondary to COVID-19 infection. Before this patient's episode, he had two prior GBS flares, each precipitated by a viral infection followed by complete recovery besides intermittent paresthesias. We also consider the nosology of this illness in the spectrum of rGBS and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP), with their differing natural histories, prognosis, and therapeutic approaches. For patients who have a history of inflammatory demyelinating polyradiculopathies who develop COVID-19, we recommend close observation for neurologic symptoms over the next days and weeks.

Facing acute neuromuscular diseases during COVID-19 pandemic: focus on Guillain-Barré syndrome.

In December 2019, a cluster of cases with 2019 Novel Coronavirus pneumonia from Wuhan, China, aroused worldwide concern due to an escalating outbreak in all the countries in the world. Coronavirus belongs to a family of single-stranded RNA viruses, which includes severe acute respiratory syndrome (SARS-CoV) and Middle East respiratory syndrome (MERS-CoV), that have caused human epidemics with high fatality. The spectrum of the novel coronavirus disease (SARS-Co-2 or COVID-19) ranges from asymptomatic infections to fatal pneumonia, and differs from other viral pulmonary infections. MERS-CoV is known to be potentially neuroinvasive. Extensive reports from China documented central and peripheral nervous system involvement in patients with COVID-19, and identified in angiotensin converting enzyme2 (ACE2), which is present in multiple human organs, the functional receptor for this virus. Guillain-Barré syndrome (GBS) has recently been associated to COVID-19 rising concern among physicians. This review summarizes the current state of knowledge on GBS during or after COVID-19 infection, attempting to clarify the pathophysiology of the associated respiratory dysfunction and failure.