A CASE OF IVIG REFRACTORY GUILLAIN-BARRÉ SYNDROME IN THE SETTING OF SUBCLINICAL COVID-19 INFECTION

ABSTRACT

TOPIC Critical Care TYPE Medical Student/Resident Case Reports INTRODUCTION: The novel coronavirus pandemic of 2019 (SARS COVID-19) has significant morbidity and mortality. The downstream complications resulting from this infection are not well characterized. There have been case reports of patients with COVID-19 infection presenting with Guillain-Barre Syndrome (GBS) Here, we present a case of one such patient, who failed initial management with intravenous immunoglobulin G (IVIG), requiring plasmapheresis as a treatment modality. CASE PRESENTATION A 48-year-old male with a past medical history of hypertension and type 2 diabetes mellitus presented to the emergency department with a four day history of progressive paresthesias and weakness. This began in his bilateral lower extremities and ascended to the bilateral upper limb and face. Concurrent mild dysarthria and dysphagia were noted. On this encounter, he had a first time positive test for COVID-19 via nasopharyngeal polymerase chain reaction (PCR). On physical exam he had reduced dorsiflexion of the right ankle, with normal power throughout the rest of the body. He had graded sensory loss in the lower extremities, without a sensory level and diminished reflexes throughout. Lumbar puncture and MRI imaging were suggestive of demyelinating neuropathy. Due to the clinical history and albuminocytologic dissociation in the CSF, he was assessed with GBS and commenced on IVIG 0.4g/kg for 5 days. On day 4 of hospitalization, worsening dysarthria and dysphagia was noted and he was transferred to the intensive care unit (ICU). Subsequently, due to lack of adequate improvement in the patient's symptoms, plasmapheresis was initiated. The patient completed 7 additional sessions of plasmapheresis and had symptom resolution. DISCUSSION: There have been several case reports of GBS in the setting of COVID-19, which has been thought to be a para-infectious in origin. According to a systematic review, 96.6% of patients affected with COVID-19 GBS experienced typical COVID-19 symptoms prior to being diagnosed with GBS. This syndrome has been seen in other viral illnesses, such as West Nile virus and the Zika virus. Most of these cases have been treated successfully with IVIG, but in this report, the patient required plasmapheresis to achieve successful resolution of his symptoms. At this time, there have been approximately three published cases of GBS in the setting of COVID-19 in the USA which required plasmapheresis as a treatment modality. Additionally, all of these cases presented with typical clinical symptoms associated with COVID-19 infection. CONCLUSIONS: This patient's findings highlight one of the first cases of GBS in the setting of sub-clinical COVID-19 infection. This adds to the growing set of literature establishing a neurological component of the disease. It also demonstrates the use of plasmapheresis as an additional tool in the treatment of COVID-19 associated GBS. REFERENCE #1 Agosti, E., Giorgianni, A., D'Amore, F., Vinacci, G., Balbi, S., & Locatelli, D. (2021). Is Guillain-Barrè syndrome triggered by SARS-CoV-2? Case report and literature review. Neurological Sciences, 42(2), 607-612. REFERENCE #2 Abrams, R. M., Kim, B. D., Markantone, D. M., Reilly, K., Paniz-Mondolfi, A. E., Gitman, M. R., … & Robinson-Papp, J. (2020). Severe rapidly progressive Guillain-Barré syndrome in the setting of acute COVID-19 disease. Journal of neurovirology, 26(5), 797-799. REFERENCE #3 Hasan, I., Saif-Ur-Rahman, K. M., Hayat, S., Papri, N., Jahan, I., Azam, R., … & Islam, Z. (2020). Guillain-Barré syndrome associated with SARS-CoV-2 infection A systematic review and individual participant data meta-analysis. Journal of the Peripheral Nervous System, 25(4), 335-343. DISCLOSURES No relevant relationships by Spencer Deleveaux, source=Web Response No relevant relationships by Sarah Usmani, source=Web Response