GUILLAIN-BARRÉ SYNDROME AND HEMOLYSIS IN COVID-19

ABSTRACT

TOPIC Chest Infections TYPE Medical Student/Resident Case Reports INTRODUCTION: The spectrum of autoimmune phenomena associated with Coronavirus disease 2019 (COVID-19) continues to expand. Guillain-Barré Syndrome (GBS) manifesting as a post-infectious sequela of COVID-19 has been increasingly reported [1]. Rare cases of autoimmune hemolytic anemia (AIHA) associated with COVID-19 are also emerging [2]. Our case describes a novel presentation of GBS and hemolysis in a patient with COVID-19. CASE PRESENTATION A 62-year-old male with a past medical history of hypertension initially presented with 5 days of low-grade fever and cough. He denied dyspnea and was not hypoxic. Nasopharyngeal PCR confirmed COVID-19. He received bamlanivimab and etesevimab infusion and was discharged from the emergency room. He returned 6 days later with new-onset unsteady gait and weakness of the lower extremities. He had 1+ reflexes in the patellar and ankle bilaterally and 3+ in both triceps and biceps. This worsened into flaccid paralysis of bilateral lower extremities by admission day 2. Labs showed a drop in hemoglobin (Hgb) from 14.7 mg/dL to 10.9 mg/dL, haptoglobin <1.0 mg/dL, lactate dehydrogenase (LDH) 742 U/L, mean corpuscular volume (MCV) 90 fL, and indirect bilirubin 1.9 mg/dL.Magnetic resonance imaging (MRI) of the brain and spine were performed, with no significant findings. Lumbar puncture was consistent with albuminocytologic dissociation, with a white cell count of 2 /mcL, and protein 78 mg/dL. CSF PCR panel was negative. Patient fulfilled Brighton criteria level 2 for GBS and was treated with 3 doses of intravenous immunoglobulin (IVIG). Following IVIG, patient weakness resolved and reflexes improved to normal. Repeat labs showed decreased LDH, normal bilirubin, improved Hgb, and negative Direct Coombs test. The patient was discharged with a GBS disability score of 0, and he continued to be symptom-free 3 weeks later. DISCUSSION: There have been increasing reports of GBS in patients with COVID-19 [1]. Most cases are treated with IVIG (77-92%) or plasmapheresis (8-11%), with about 35% of patients having residual deficits (GBS disability score >2) at time of discharge [1, 3]. AIHA has also been associated with COVID-19, with mixed warm and cold agglutin formation [2]. A negative CSF PCR panel with high protein suggests that novel antibodies may mediate myelin damage, which may also target other components such as fibrinogen in α/β chains. Immunoglobulin fragment alteration resulting in molecular mimicry may also occur following antigen-antibody complex formation directed against the virus [1]. CONCLUSIONS: GBS and AIHA are rare but important complications in patients with COVID-19. The spectrum of autoimmune phenomena associated with COVID-19 continues to expand. This case highlights the need for the differential to include autoimmune disease in patients with extrapulmonary manifestations of COVID-19. Further studies are needed to determine if causal relationships are present. REFERENCE #1 Sheikh AB, Chourasia PK, Javed N, et al. Association of Guillain-Barre syndrome with COVID-19 infection An updated systematic review. 2021 Apr 18. J Neuroimmunol. 2021;355577577. doi10.1016/j.jneuroim.2021.577577 REFERENCE #2 Lazarian G, Quinquenel A, Bellal M, et al. Autoimmune haemolytic anaemia associated with COVID-19 infection. Br J Haematol. 2020;190(1)29-31. doi10.1111/bjh.16794 REFERENCE #3 Hasan I, Saif-Ur-Rahman KM, Hayat S, et al. Guillain-Barré syndrome associated with SARS-CoV-2 infection A systematic review and individual participant data meta-analysis. J Peripher Nerv Syst. 2020 Dec;25(4)335-343. doi 10.1111/jns.12419. DISCLOSURES No relevant relationships by Mateus Fernandes, source=Web Response No relevant relationships by Ifediba Nwachukwu, source=Web Response