More Bad News About COVID-19

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Puja Singh

Puja Singh. M4 at Cooper Medical School of Rowan University currently applying to Emergency Medicine residency. Critical care, global health, Meded, food, and puppy enthusiast!

The Pre-brief

Is there a link between Coronavirus and Guillain-Barre Syndrome?

As the COVID pandemic sweeps across the world, the novel SARS-CoV-2 virus claims more and more lives each day. The unknowns surrounding this virus have been a challenge and have especially been frustrating for medical professionals around the globe. As fear builds in the  public, patients are utilizing emergency care less.

Adding to the chaos of COVID, cases of concomitant COVID-19 and Guillain-Barre Syndrome (GBS) have been reported in China, Italy, Spain, Iran, and the United States. In these cases patients presented with symptoms such as lower extremity paresthesia, weakness, and paralysis, and ataxia. Classically, Guillain-Barre has been linked to other infections such as Campylobacter, Cytomegalovirus, Zika, Ebstein Barr, and Influenza; however, now there is growing concern for a link between GBS and COVID-19. 

What is Guillain-Barre Syndrome? We all know it as the autoimmune disease we are taught about in medical school, attacking our immune system, damaging the peripheral nervous system, and destroying myelin, with resulting ascending paralysis and the “albuminocytologic dissociation” classically observed on lumbar puncture. Throughout this pandemic however, there has been concern as to whether SARS-CoV-2 will cause GBS and if so, how will it present? How will we diagnose it? How will it be different?

For the most part, patients who suffer from GBS improve within a few weeks, making a full recovery. In some cases, however, it can progress to a deadly respiratory failure due to paralysis of the diaphragmatic muscles. It is our job in Emergency Medicine and Critical Care to prevent, if possible, the progression of any illness to  mechanical ventilation. Combining this disease with the deleterious respiratory effects of COVID-19, healthcare workers face a mounting clinical situation filled with stress and uncertainty.

An article published in The New England Journal of Medicine, “Guillain-Barre Syndrome Associated with SARS-CoV-2” describes 5 patients in Italy who suffered from GBS and COVID-19. Their symptoms evolved over a range of 36 hours to 4 days and three patients progressed to respiratory failure requiring mechanical ventilation. No patient progressed to symptoms consistent with dysautonomia. Interestingly, two patients had a normal protein level in their CSF while all the patients had a lower than normal white blood cell in their CSF.

There is little evidence thus far to link GBS to COVID-19 directly, but given the importance of this potential association, the Neurocritical Care Society has advocated for a unified approach to report COVID-19 patients who develop neurological complications. They are leading a multi-center, international collaborative effort to collect data from medical centers to create a large dataset that can be available for future analysis and guide the development of diagnostic and therapeutic guidelines.

Many questions remain: 1) How exactly is GBS linked to COVID-19? 2) What antibodies are responsible for the neurotoxic effects? 3) What is the chance that someone will develop GBS when infected with COVID-19? 4) Is this relationship a coincidence or are these diseases truly linked? More research is needed to better understand the connection between these two diseases. Although only a few GBS cases linked to COVID-19 have been reported, it is possible that there are more out there. Be on the lookout for the dangerous duo of COVID-19 and GBS in your emergency department and intensive care unit.

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