COVID-induced Severe Global Axonal Neuropathy and Association with Anti-ganglioside Antibodies: A Case Report

ABSTRACT

Case Diagnosis Severe global axonal neuropathy Case Description or Program Description A 36-year-old healthy male presented with fever and body aches, found to be COVID positive. During hospitalization, he became hypoxic and obtunded, requiring emergent intubation. Physical exam notable for flaccid paralysis of extremities with diffuse atrophy. Patient opened his eyes without following commands. He was treated with a prolonged course of steroids, Remdesivir and antibiotics for COVID-19 pneumonia. Due to diffuse weakness, Nerve Conduction Studies (NCS)/ Electromyography (EMG) performed showed acute motor and sensory axonal neuropathy (AMSAN), a severe subtype of acute inflammatory demyelinating polyneuropathy (AIDP). Subsequently, the patient received 5 days of IVIG and 7 sessions of plasmapheresis but failed extubation. Setting(s) University hospital Assessment/Results: On NCS, the patient had absent sensory and motor responses to direct stimulation in the extremities. The sensory study included radial, ulnar, median and sural nerves. The motor studies included musculocutaneous, median, ulnar, peroneal and tibial nerves. EMG of selected extremities revealed fibrillations in all major muscle groups. Muscle recruitment was not assessed due to mental status. Neurological work-up including CTH and MRI spine was negative for a central process. LP was inconclusive. Additional studies notable for anti-ganglioside GQD1 antibody positive. Discussion (relevance) There continues to be neuromuscular compromise precipitated by COVID-19. The patient presented with global weakness of the entire musculature including the muscles of respiration. As evidenced by anti-GQ D1 IgG antibody and NCS/EMG, the patient presented with acute motor and sensory axonal neuropathy (AMSAN), which is the most severe form of AIDP. Conclusion(s) Within the literature, anti-ganglioside antibodies occur within 25% of AIDP and 50% of patients with the axonal variant of AIDP. There has been previous investigation regarding the relationship of Anti-ganglioside GM antibodies in GBS and the relationship with Campylobacter Jejuni infection. It is important to identify that this same relationship may be present with COVID-19, necessitating further research.