Guillain-Barré syndrome associated with COVID-19: A systematic review

Updates on the neurological manifestations of SARS-CoV-2 infection

PURPOSE OF REVIEW

Since its emergence in 2020, the COVID-19 pandemic has created a global surge of survivors experiencing neurologic effects from SARS-CoV-2 infection. This review aims to provide an updated synthesis of the acute and chronic neurological manifestations of COVID-19, and to outline the current therapeutic strategies for these conditions.

RECENT FINDINGS

Epidemiological studies have shown that COVID-19 patients with neurological symptoms during acute infection tend to have poorer hospital and functional outcomes. While the risk of adverse neurologic symptoms including cognitive dysfunction, headache, autonomic dysfunction, and chronic fatigue are thought to be greatest following infection with the original SARS-CoV-2 strain and its alpha variant, they remain prevalent after infection with subsequent less virulent strains as well. Some recent work has also found a link between SARS-CoV-2 and structural brain changes. However, ongoing trials show promising results for pharmacologic and nonpharmacologic treatments targeting the postacute neurological sequelae of COVID-19.

SUMMARY

Lingering neurological manifestations after COVID-19 still pose considerable individual, healthcare system, and socioeconomic repercussions. Both preventive and multimodal treatment approaches are necessary to address these conditions. Further research is required to assess the lasting impacts of SARS-CoV-2 on the nervous system, particularly its potential contribution to the development of neurodegenerative diseases.

Guillain-Barré Syndrome During the Outbreak of Omicron in Southern China: A Multicenter Case-Control Study

Purpose

The largest nationwide outbreak of Omicron, a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) variant, occurred between December 2022 and February 2023 in China. This multicenter case-control study investigated the clinical features of GBS during this period.

Methods

The clinical characteristics of patients diagnosed with GBS associated with SARS-CoV-2 were assessed during an Omicron outbreak at 14 referral hospitals in Hubei Province, Southern China. In the case-control study, patients with GBS were identified and diagnosed between 2021 and 2022 at Tongji Hospital in Wuhan, Hubei province.

Results

Forty-one patients were diagnosed with GBS during the Omicron outbreak. The median patient age was 57.5 years, and 51.2% were male. The median period between the preceding infection and onset of neurological symptoms was 10 days. The majority of the patients (38 cases [92.7%]) presented with classic sensorimotor neuropathy, with the lower limbs involved more often; 17 cases (41.5%) were accompanied by cranial neuropathies, which was most observed with the bilateral or unilateral facial paralysis (13 cases [31.7%]). Albuminocytologic dissociation was observed in 27 patients (71.1%), and mild pleocytosis was found in five patients (12.2%), with a maximum of 22 cells/mm3. Thirty-two patients finished the electrophysiological studies, and axonal variants were confirmed in 21 cases predominantly as acute motor-sensory axonal neuropathy (40.6%) or acute motor axonal neuropathy (25.0%). Anti-ganglioside antibodies were detected in 19 patients (46.3%). Intravenous immunoglobulin administration improved the patients' symptoms.

Conclusion

The characteristics of SARS-CoV-2-associated GBS during the Omicron outbreak appear clinically as sensorimotor neuropathy, with a predominant electrophysiological axonal form. A mainly classic post-infectious immune-mediated mechanism may be involved in this process, such as a temporal profile of clinical symptoms, axon-associated autoantibodies, and improvement by immunotherapy.

Identifying potential co-expressed genes and molecular mechanisms linking post-COVID-19 and Guillain-Barre syndrome through neutrophil extracellular trap-related genes

Introduction

Neutrophil extracellular traps (NETs) play a pivotal role in immunity and autoinflammatory disease, leading us to hypothesize that NETs are crucial in Guillain-Barre Syndrome (GBS) after SARS-CoV-2 infection.

Methods

By collecting six Gene Expression Omnibus (GEO) datasets from the GEO database and dividing them into discovery and validation sets, we screened differentially expressed genes (DEGs) within the discovery set, with further analyses using functional enrichment analysis. Using single-sample gene set enrichment analysis (ssGSEA), we assessed immune cell infiltration in both coronavirus disease 2019 (COVID-19) and GBS datasets. NETs-related genes (NETRGs) were identified through a protein-protein interaction (PPI) network and NETs gene datasets. Finally, candidate drugs were screened using Connectivity Map.

Results

In this study, a total of 3254 DEGs were identified from the COVID-19 dataset, and 692 DEGs were obtained from the GBS dataset. Among these, 145 co-expressed DEGs were obtained. Bioinformatics functional analysis indicated that co-expressed DEGs were predominantly gathered in immune-related and inflammatory response pathways. Employing various algorithms, we identified MMP9, CAMP, and CASP1 as NETRGs, demonstrating good discriminatory capacity in COVID-19 and GBS. Notably, neutrophils and macrophages were identified as co-upregulated differential immune infiltrating cells significantly associated with both COVID-19 and GBS. Moreover, we identified 10 candidate drugs for patients with post-COVID-19 GBS.

Conclusion

In conclusion, MMP9, CASP1, and CAMP were identified as promising biomarkers and potential targets for therapy of post-COVID-19 GBS.

Domingo FG, Longley S, Patel S, Baddam S, Chimakurthy A. Post-COVID-19 Guillain-Barré Syndrome with GM1 and GD1b Antibodies: A Case Study and Literature Review

BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to the emergence of various neurological complications, including Guillain-Barre syndrome (GBS). GBS is an acute, immune-mediated disorder characterized by progressive weakness, sensory deficits, and autonomic dysfunction. Anti-ganglioside antibodies are often seen in GBS; however, they are rarely reported in the setting of COVID-19-related GBS. We present a case of post-COVID-19 GBS with positive GM1 and GD1b antibodies. CASE REPORT An 86-year-old man presented with progressive quadriparesis, sensory deficits, and hyporeflexia 4 weeks after COVID-19 infection. Brain and spine imaging were unremarkable. Cerebrospinal fluid (CSF) analysis revealed albuminocytological dissociation, consistent with acute inflammatory demyelinating polyneuropathy (AIDP). Despite 2 courses of intravenous immunoglobulin (IVIG), the patient showed minimal improvement in muscle strength. Nerve conduction studies (NCS) revealed severe sensorimotor polyneuropathy, with axonal and demyelinating features. Serum testing showed elevated GM1 and GD1b anti-ganglioside antibody titers. CONCLUSIONS Although numerous cases of COVID-19-related GBS have been reported, anti-ganglioside antibody positivity, particularly GM1 and GD1b, is uncommon. The underlying mechanism is presumed to be autoimmune, likely triggered by molecular mimicry. Our case contributes to the evolving understanding of GBS immunology in the context of COVID-19. Although this case report may not alter current GBS management, the co-occurrence of GM1 and GD1b antibodies in post-COVID-19 GBS underscores the need for continued vigilance, immunological profiling, and research into potential prognostic and therapeutic implications.

COVID-19 and neuropathy in type 2 diabetes

This study investigated the risk factors for COVID-19 and its impact on diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes (T2D). Patients with T2D underwent assessments with the NICE post-COVID questionnaire, DN4 questionnaire, vibration perception threshold (VPT), and corneal confocal microscopy (CCM) before and 11.0 ± 8.9 months after developing COVID-19. Of 76 participants with T2D, 35 (46.1%) developed COVID-19, of whom 8 (22.9%) developed severe COVID-19 and 9 (25.7%) developed long-COVID. The development of COVID-19 was associated with lower systolic blood pressure (P < 0.05). The presence and severity of DPN were not associated with developing COVID-19, severe COVID-19, or long-COVID (P = 0.42-0.94). Women were eight times more likely to develop long-COVID (P < 0.05) and elevated body weight, LDL, and VPT were associated with the development of long-COVID (P < 0.05 - 0.01). The long-COVID group exhibited significant changes in triglycerides and LDL (P < 0.05 for both) and body weight (P < 0.01) at follow-up. Their impact on clinical and neuropathy measures was comparable in patients with and without COVID-19 (P = 0.08-0.99). There was a significant reduction in corneal nerve measures (P < 0.05-0.0001) in patients with and without COVID-19. A low systolic blood pressure, altered lipids, body weight, higher VPT, and gender may determine the impact of COVID-19 in patients with T2D, but there was no evidence of an impact of COVID-19 on the development or progression of DPN.

Is there a link between Hepatitis A virus and Guillain-Barré syndrome? A systematic review of case reports

Introduction

Guillain-Barré syndrome (GBS) is an inflammatory disorder of the peripheral nervous system, causing acute flaccid paralysis. There have been occasional reports linking Hepatitis A virus (HAV) to GBS. Here we aimed to evaluate the current literature on the association between GBS and HAV, exploring potential mechanisms and clinical implications.

Methods

We conducted a systematic search using PRISMA guidelines in PubMed, Web of Science, Embase, and Scopus. Only published case reports or conference abstracts presenting cases of confirmed HAV infection and GBS were included. Data extraction was performed independently by two reviewers, and quality assessment was conducted using the Joanna Briggs Institute critical appraisal tool.

Results

Out of 581 studies identified, 46 studies encompassing 47 cases met the inclusion criteria. The mean age of patients was 29.47 years, with a male predominance (70.2 %). Geographically, most cases were reported in Asia (74.5 %). Clinical manifestations of HAV included fever, malaise, and jaundice, while GBS presented with muscle weakness and areflexia. Laboratory findings showed albuminocytological dissociation in 76.2 % of cases. Nerve conduction studies predominantly indicated AIDP subtype (32/46, 69.6 %). Treatment involved IVIG, plasmapheresis, and supportive care, with recovery times ranging from one week to 18 months. One fatality was reported.

Conclusions

This review suggests a potential link between HAV infection and GBS, proposing a mechanism: molecular mimicry. It emphasizes the need for increased awareness and preventive measures, especially in areas with lower health standards. However, further research is needed to clarify the possible mechanisms and deepen our understanding.

Post COVID-19 and Long COVID Symptoms in Otorhinolaryngology-A Narrative Review

Post/Long COVID (syndrome) is defined as a condition with symptoms persisting for more than 12 weeks after the onset of SARS-CoV-2 infection that cannot be explained otherwise. The prevalence of self-reported otorhinolaryngological Post/Long COVID symptoms is high. The aim of this review was to analyze the current literature regarding the actual prevalence, knowledge of the etiopathology, and evidence-based treatment recommendations of otorhinolaryngology-related Post/Long COVID symptoms. A systematic literature search of articles published since 2019 in PubMed and ScienceDirect was performed and resulted in 108 articles. These were the basis for this review and formed a comprehensive series of consented therapy statements on the most important of otorhinolaryngology-related Post/Long COVID symptoms. Otorhinolaryngological symptoms did not appear isolated but as part of a multi-organ syndrome. Self-reported otorhinolaryngology-related Post/Long COVID symptoms were often not confirmed by objective testing. The confirmed prevalence estimated for anosmia, dysgeusia, cough, facial palsy, hoarseness/dysphonia, acute hearing loss, tinnitus, and vertigo/dizziness was about 4%, 2%, 4-19%, 0%, 17-20%, 8%, 20%, and 5-26%, respectively. There are manifold theoretical concepts of the etiopathology of different symptoms, but there is no clear evidence-based proof. This certainly contributes to the fact that there is no effective specific treatment option for any of the symptoms mentioned. Healthcare pathways must be established so that otorhinolaryngological Post/Long COVID symptoms can be recognized and evaluated and otorhinolaryngologists can provide counseling. This would also help to establish and selectively include patients in clinical trials investigating specific therapeutic concepts.

Intrinsic Factors Behind the Long-COVID: V. Immunometabolic Disorders

The complex link between COVID-19 and immunometabolic diseases demonstrates the important interaction between metabolic dysfunction and immunological response during viral infections. Severe COVID-19, defined by a hyperinflammatory state, is greatly impacted by underlying chronic illnesses aggravating the cytokine storm caused by increased levels of Pro-inflammatory cytokines. Metabolic reprogramming, including increased glycolysis and altered mitochondrial function, promotes viral replication and stimulates inflammatory cytokine production, contributing to illness severity. Mitochondrial metabolism abnormalities, strongly linked to various systemic illnesses, worsen metabolic dysfunction during and after the pandemic, increasing cardiovascular consequences. Long COVID-19, defined by chronic inflammation and immune dysregulation, poses continuous problems, highlighting the need for comprehensive therapy solutions that address both immunological and metabolic aspects. Understanding these relationships shows promise for effectively managing COVID-19 and its long-term repercussions, which is the focus of this review paper.

Peripheral Immune-Mediated Neuropathy Before and During the COVID-19 Pandemic: A Retrospective Cross-Sectional Study in a Referral Center

BACKGROUND

There are currently seven coronaviruses that can infect humans and the latest addition to these viruses is the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Infection by SARS-CoV-2 is known commonly as coronavirus disease 2019 (COVID-19). Aside from common manifestations of cough and fever, neurologic symptoms such as headache, disturbed consciousness, paresthesia, and seizures have also been seen. By identifying the incidence of peripheral immune-mediated neuropathies (PIMN), early prevention can be made.

METHODS

This cross-sectional retrospective analytic study reviewed the case records of patients examined at the Center for Neurodiagnostic and Therapeutic Services (CNS) of Metropolitan Medical Center from January 2018 to December 2021.

RESULTS

The period incidence of Guillain-Barré Syndrome (GBS) for the years 2018-2019 and 2020-2021 were 9.21% and 24.44%, respectively. The obtained p-value was 0.0226, which was lower than the set p-value of 0.05. Therefore, the period incidence of GBS for 2020-2021 was significantly higher when compared to that of 2018-2019.

CONCLUSION

There has been an increase in cases of GBS during the COVID-19 pandemic.

Mortality and its predictors among patients with Guillain-Barré syndrome in the intensive care unit of a low-income country, Ethiopia: a multicenter retrospective cohort study

Background

Guillain-Barré syndrome (GBS) is a rare autoimmune disease that affects the peripheral nervous system. It is characterized by the destruction of nerves involved in movement. This condition can lead to transient pain, changes in temperature and touch sensations, muscle weakness, loss of sensation in the legs and/or arms, and difficulty swallowing or breathing. Published data on the outcomes of critical care for patients with GBS are extremely scarce in Africa, particularly Ethiopia. Therefore, this study aimed to assess mortality and its predictors among patients with GBS in the intensive care unit (ICU) of specialized hospitals in Ethiopia, a low-income country.

Materials and methods

This retrospective cohort study was conducted at the Tibebe Ghion Specialized Hospital and the Felege Hiwot Comprehensive Specialized Hospital in Bahir Dar, Ethiopia, from 1 January 2019 to 30 December 2023. Data were collected in the medical record rooms. Cox regression analysis was performed to identify the predictors of mortality among GBS patients in the ICU. The crude and adjusted hazard ratios (AHRs) and 95% confidence intervals (CIs) were calculated using bivariable and multivariable Cox regression models. A p-value of <0.05 was considered statistically significant.

Results

Of 124 GBS patients admitted to the ICU, 120 were included in the final analysis. During the follow-up, there were 23 (19.17%) deaths. The overall incidence rate of death was 1.96 (95% CI: 1.30, 2.95) per 100 person-days of observation. Traditional medicine (AHR = 3.11, 95%: 1.12, 16.70), COVID-19 infection (AHR = 5.44, 95% CI: 1.45, 73.33), pre-ICU cardiac arrest (AHR = 6.44, 95% CI: 2.04, 84.50), and ICU readmission (AHR = 4.24, 95% CI: 1.03, 69.84) were identified as the independent predictors of mortality.

Conclusion

The mortality rate among GBS patients admitted to the ICU was high. Traditional medicine, COVID-19 infection, pre-ICU cardiac arrest, and readmission to the ICU were the significant predictors of mortality. Conducting large-scale studies with a prospective design in the future would yield more robust evidence.

Case report: Rare Guillain-Barré syndrome variants and mild encephalitis/encephalopathy with a reversible splenial lesion as the para-infectious manifestations of SARS-CoV-2 infection

Background

The Coronavirus disease 19 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a threat to human health. Although the COVID-19 pandemic is finished, some peoples are still suffering from this disease. Herein, we report the first case of SARS-CoV-2-associated Guillain-Barré syndrome (GBS) presenting as polyneuritis cranialis (PNC) and acute panautonomic neuropathy (APN) variants, accompanied by mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) and hyponatremia.

Case presentation

A 32-year-old female patient with symptoms indicating multiple cranial nerve involvement, as well as sympathetic and parasympathetic nervous system dysfunction, was diagnosed as SARS-CoV-2-associated GBS presenting as PNC and APN variants, accompanied by MERS and hyponatremia. Following treatment with immunoglobulin, methylprednisolone, and symptomatic care, the patient's inflammatory cytokines and serum sodium became normal. However, some residual symptoms such as postural hypotension, fatigue, and mild dysarthria persisted at the 9-month follow-up.

Conclusion

This case highlights the unique presentation of SARS-CoV-2 infection. The involvement of both the central nervous system (CNS) and the peripheral nervous system (PNS) in this case underscores the complex neurological manifestations of COVID-19. Although the exact underlying pathogenesis of this case is unclear, inflammatory cytokines, particularly IL-6, may be implicated. Further research is needed to better understand the mechanisms underlying these complications and to optimize treatment strategies for affected patients.

Prevalence and Mortality of Pediatrics with Guillain-Barré Syndrome during the COVID-19 Pandemic and Pre-COVID-19 Periods

Objectives

Based on case reports, researchers have observed the incidence and clinical manifestations of Guillain-Barré Syndrome (GBS) following COVID-19 infection. Current hypotheses suggest that the risk of GBS may increase with COVID-19, and worsening GBS could elevate the risk of infection and exposure to the virus. This study aimed to assess the cognitive epidemic and mortality of children under 15 years of age with GBS during the COVID-19 pandemic and to compare them to two years earlier without addressing the etiology.

Materials & Methods

This cross-sectional study was conducted on all children admitted to Iranian hospitals with a diagnosis of GBS and whose clinical information was available in the national flaccid paralysis patient information registration system between April 2018 and April 2021.

Results

The total number of registered cases of GBS in the pre-COVID-19 period and during this period was 778 cases and 504 cases, respectively (total N=1282), indicating a decrease in registered GBS during COVID-19. The mean age of the patients in the pre-COVID-19 period was 9.00 ± 2.78 years, and during the COVID-19, it was 8.99 ± 2.03 years (P-value =0.998). No significant difference was found in gender distribution between the two periods (P-value =0.427). The total number of paralysis cases studied after 60 days was 14.3% before the COVID-19 period and 17.3% during the pandemic (P-value =0.216). The mortality rate in patients with GBS was 0.13% in the pre-COVID-19 period and 0.19% in the COVID-19 period (P-value =0.757).

Conclusion

Despite the decline in the frequency of diagnosis and referrals of patients with GBS during the COVID-19 period, no difference was found in the demographic characteristics and clinical outcomes of children with GBS in the pre-COVID-19 period and during this pandemic.

Temporal trends and regional variations in mortality related to Guillain-Barré syndrome in the United States: a retrospective study from 1999 to 2020

AIM

Guillain-Barré syndrome (GBS) is an autoimmune neurological disorder, with an estimated 6.4% increase in cases worldwide from 1990 to 2019. We aim to identify the GBS-related mortality trends in the US stratified by age, sex, race, and region.

METHODS

We used data from the CDC-WONDER database to calculate crude (CMR) and age-adjusted mortality rates (AAMRs) per 1,000,000 people. We examined the temporal trends through annual percent change (APC) and the average annual percent change (AAPC) in rates using Joinpoint regression.

RESULTS

From 1999 to 2020, a total of 10,097 GBS-related deaths occurred in the US. The AAMR decreased till 2014 (APC: -1.91) but increased back to initial levels by 2020 (APC: 3.77). AAMR was higher in males (1.7) than females (1.1), decreasing till 2015 for females and 2014 for males, but increasing thereafter only for females. Non-Hispanic (NH) American Indians or Alaska Natives displayed the highest AAMR (1.8) while NH Asians or Pacific Islanders displayed the lowest (0.6). AAMRs also varied by region (West: 1.5; South: 1.5; Midwest: 1.4; Northeast: 1.1). Rural regions exhibited a higher AAMR (1.7) than urban regions (1.3). Most deaths occurred in medical facilities (60.99%). The adults aged ≥85 years exhibited an alarmingly high CMR (14.0).

CONCLUSIONS

While the mortality rates for GBS initially declined till 2014, they climbed back up afterwards. Highest mortality was exhibited by males and NH American Indians or Alaska Natives, residents of rural regions, and adults ≥85 years. Equitable efforts are needed to reduce the burden on high-risk populations.

Long COVID Definition, Symptoms, Risk Factors, Epidemiology and Autoimmunity: A Narrative Review

The virus called SARS-CoV-2 emerged in 2019 and quickly spread worldwide, causing COVID-19. It has greatly impacted on everyday life, healthcare systems, and the global economy. In order to save as many lives as possible, precautions such as social distancing, quarantine, and testing policies were implemented, and effective vaccines were developed. A growing amount of data collected worldwide allowed the characterization of this new disease, which turned out to be more complex than other common respiratory tract infections. An increasing number of convalescents presented with a variety of nonspecific symptoms emerging after the acute infection. This possible new global health problem was identified and labelled as long COVID. Since then, a great effort has been made by clinicians and the scientific community to understand the underlying mechanisms and to develop preventive measures and effective treatment. The role of autoimmunity induced by SARS-CoV-2 infection in the development of long COVID is discussed in this review. We aim to deliver a description of several conditions with an autoimmune background observed in COVID-19 convalescents, including Guillain-Barré syndrome, antiphospholipid syndrome and related thrombosis, and Kawasaki disease highlighting a relationship between SARS-CoV-2 infection and the development of autoimmunity. However, further studies are required to determine its true clinical significance.

Lingering effects of COVID-19 in the care of perioperative patients

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can lead to organ dysfunction and clinical symptoms beyond the acute infection phase. These effects may have significant implications for the management of perioperative patients. The purpose of this article is to provide a systems-based approach to the subacute and chronic effects of SARS-CoV-2 that are most relevant to anesthesiology practice.

RECENT FINDINGS

In 2024, COVID-19 remains a concern for anesthesiologists due ongoing new infections, evolving viral strains, and relatively low rates of booster vaccination in the general population. A growing body of literature describes the post-COVID-19 syndrome in which patients experience symptoms more than 12 weeks after acute infection. Recent literature describes the lingering effects of SARS-CoV-2 infection on all major organ systems, including neurologic, pulmonary, cardiovascular, renal, hematologic, and musculoskeletal, and suggests an increased perioperative mortality risk in some populations.

SUMMARY

This review offers anesthesiologists an organ system-based approach to patients with a history of COVID-19. Recognizing the long-term sequelae of SARS-CoV-2 infection can help anesthesiologists to better evaluate perioperative risk, anticipate clinical challenges, and thereby optimize patient care.

Relative frequencies and clinical features of Guillain-Barré Syndrome before and during the COVID-19 pandemic in North China

OBJECTIVE

Most studies investigated the relationship between COVID-19 and Guillain-Barré syndrome (GBS) by comparing the incidence of GBS before and during the pandemic of COVID-19. However, the findings were inconsistent, probably owing to varying degrees of the lockdown policy. The quarantine requirements and travel restrictions in China were lifted around December 7, 2022. This study aimed to explore whether the relative frequency of GBS increased during the major outbreak in the absence of COVID-19-mandated social restrictions in China.

METHODS

GBS patients admitted to the First Hospital, Shanxi Medical University, from December 7, 2022 to February 20, 2023, and from June, 2017 to August, 2019 were included. The relative frequencies of GBS in hospitalized patients during different periods were compared. The patients with and without SARS-CoV-2 infection within six weeks prior to GBS onset formed the COVID-GBS group and non-COVID-GBS group, respectively.

RESULTS

The relative frequency of GBS among hospitalized patients during the major outbreak of COVID-19 (13/14,408) was significantly higher than that before the COVID-19 epidemic (29/160,669, P < 0.001). More COVID-GBS patients (11/13) presented AIDP subtype than non-COVID-GBS cases (10/27, P = 0.003). The mean interval between onset of infective symptoms and GBS was longer in COVID-GBS (21.54 ± 11.56 days) than in non-COVID-GBS (5.76 ± 3.18 days, P < 0.001).

CONCLUSIONS

COVID-19 significantly increased the incidence of GBS. Most COVID-GBS patients fell into the category of AIDP, responded well to IVIg, and had a favorable prognosis.

The Review of Ophthalmic Symptoms in COVID-19

The COVID-19 pandemic caused by SARS-CoV-2 had a significant impact on the health of the global human population, affecting almost every human organ, including the organ of vision. Research focus on understanding the pathophysiology, identifying symptoms and complications of the disease. Eye-related pathologies are important foci of research due to the potential for direct impact of the virus. Ophthalmologists around the world are reporting various symptoms of eye infections and ocular pathologies associated with SARS-CoV-2. The review of ophthalmic symptoms was conducted to help physicians of various specialties recognize possible ophthalmic manifestations of this viral disease. A literature review was conducted from January 2020 to July 2023 in the PubMed, MEDLINE, Science Direct, Scopus, Scielo and Google Scholar databases. The review of the literature showed that conjunctivitis is the most common ophthalmic symptom observed during the course of COVID-19 and can occur at any stage of the disease. Changes in the eye may result from the direct effect of the virus, immune response, prothrombotic states, comorbidities, and medications used. Symptoms related to the organ of vision can be divided into: changes affecting the protective apparatus of the eye, the anterior eye segment, the posterior eye segment, neuro-ophthalmic, and orbital changes. Ocular symptoms may suggest COVID-19 infection or appear several weeks after recovery. Following COVID-19 vaccinations, a diverse range of ophthalmic symptoms was observed in various locations and at different times, mirroring the ocular symptoms experienced throughout the course of the COVID-19 illness. It is important for physicians of all specialties to be aware of possible potential connections between eye diseases and SARS-CoV-2, in order to effectively diagnose and treat patients.

Guillain-barré syndrome (GBS) with antecedent chikungunya infection: a case report and literature review

Guillain-Barré Syndrome (GBS) is an autoimmune neuropathy. Antecedent infections have been seen to be significant triggering factors for developing GBS. Among them, arboviral infections are rapidly gaining importance as significant triggers, especially in the areas where they are endemic. Chikungunya, an arboviral infection that usually causes a self-limiting acute febrile illness can lead to GBS as one its severe complications. Herein, we describe a case of a 21-year-old female who presented with weakness in all four limbs and paresthesia. Nerve conduction study and cerebrospinal fluid (CSF) analysis showed axonal, demyelinating motor and sensory neuropathy with albuminocytological dissociation indicating Acute Motor and Sensory Axonal Neuropathy (AMSAN) variant of GBS. Serum IgM antibodies against ganglioside GM1 were detected. Anti-Chikungunya IgM antibodies were found in both serum and CSF samples. The patient was initiated with Intravenous Immunoglobulin (IVIG) therapy. In view of hypoxia, she was intubated and was on mechanical ventilation. After 2 weeks of being comatose, the patient gradually improved and was discharged with no sequelae.A literature review on antecedent infections in GBS is presented alongside the case report to better understand the association of GBS with antecedent infections, especially the endemic arboviral infections like Chikungunya, Dengue and Zika. This will help in reinforcing the significance of having robust surveillance and public health control measures for infectious diseases.

Rehabilitation of Rare Neurological Complications of COVID-19 Infection in Health Resort Settings

There is increasing evidence of neurological involvement in patients with coronavirus disease. Reports of neurological manifestations include altered mental status, Guillain-Barré syndrome (GBS) and its forms, encephalopathy, psychosis, neurocognitive (dementia) syndrome, ischemic strokes, intracerebral hemorrhage, and acute transverse myelitis. We present three patients with rare neurological manifestations of the COVID-19 disease, with a special focus on rehabilitation in a health resort setting. Outcomes were evaluated based on neurological examination and the modified Barthel index. We highlight the importance of an interdisciplinary approach to reduce disability and improve functionality and quality of life.

Guillain-Barré Syndrome After a SARS-CoV-2 Vaccine

The worldwide mass vaccination campaign against COVID-19 has been the largest one ever undertaken. Although the short-term safety profile of the different vaccines has been well established, neuroinflammatory complications have been described, including rare cases of acute demyelinating inflammatory polyneuropathy. We report a 63-year-old man who presented to the emergency department with proximal muscle weakness and paresthesia. He had received the first dose of the AZD1222 SARS-CoV-2 vaccine (Oxford, AstraZeneca) two weeks before presentation. The diagnosis of Guillain-Barré syndrome (GBS) was confirmed by clinical features, cerebrospinal fluid analysis, and electromyography. On the second hospital day, progression to flaccid tetraplegia, cranial nerve involvement, and respiratory failure, requiring invasive mechanical ventilation, were noted, and he was admitted to the intensive care unit. Despite the prompt diagnosis and immunosuppressive treatment initiation, the patient was left with severe disability. Although the COVID-19 vaccination was generally safe and socially beneficial, individual adverse reactions, including neuroinflammatory severe complications, may occur.

Is COVID-19 Infection a Multiorganic Disease? Focus on Extrapulmonary Involvement of SARS-CoV-2

First described in December 2019 in Wuhan (China), COVID-19 disease rapidly spread worldwide, constituting the biggest pandemic in the last 100 years. Even if SARS-CoV-2, the agent responsible for COVID-19, is mainly associated with pulmonary injury, evidence is growing that this virus can affect many organs, including the heart and vascular endothelial cells, and cause haemostasis, CNS, and kidney and gastrointestinal tract abnormalities that can impact in the disease course and prognosis. In fact, COVID-19 may affect almost all the organs. Hence, SARS-CoV-2 is essentially a systemic infection that can present a large number of clinical manifestations, and it is variable in distribution and severity, which means it is potentially life-threatening. The goal of this comprehensive review paper in the series is to give an overview of non-pulmonary involvement in COVID-19, with a special focus on underlying pathophysiological mechanisms and clinical presentation.

Autoimmune Autonomic Neuropathy: From Pathogenesis to Diagnosis

Autoimmune autonomic ganglionopathy (AAG) is a disease of autonomic failure caused by ganglionic acetylcholine receptor (gAChR) autoantibodies. Although the detection of autoantibodies is important for distinguishing the disease from other neuropathies that present with autonomic dysfunction, other factors are important for accurate diagnosis. Here, we provide a comprehensive review of the clinical features of AAG, highlighting differences in clinical course, clinical presentation, and laboratory findings from other neuropathies presenting with autonomic symptoms. The first step in diagnosing AAG is careful history taking, which should reveal whether the mode of onset is acute or chronic, followed by an examination of the time course of disease progression, including the presentation of autonomic and extra-autonomic symptoms. AAG is a neuropathy that should be differentiated from other neuropathies when the patient presents with autonomic dysfunction. Immune-mediated neuropathies, such as acute autonomic sensory neuropathy, are sometimes difficult to differentiate, and therefore, differences in clinical and laboratory findings should be well understood. Other non-neuropathic conditions, such as postural orthostatic tachycardia syndrome, chronic fatigue syndrome, and long COVID, also present with symptoms similar to those of AAG. Although often challenging, efforts should be made to differentiate among the disease candidates.

Guillain-Barré Syndrome After COVID-19 Infection in Korea: A Case Series

Guillain-Barré syndrome (GBS) is an autoimmune-driven condition characterized by acute polyneuropathy, often emerging as a sequel to prior infections or vaccinations. This study presents the first reported cases of GBS emerging after the full recovery from coronavirus disease 2019 (COVID-19) infection in Korea. Despite experiencing mild acute COVID-19 symptoms, these patients faced substantial weakness attributed to GBS, significantly affecting their daily lives. The timely administration of intravenous immunoglobulin treatment halted the progression of symptoms, underscoring the critical importance of early intervention. These cases highlight the potential for neurological complications associated with COVID-19 and underscore the necessity for continuous monitoring and timely medical care.

Graves' Disease Exacerbation with Impending Thyroid Storm After SARS-CoV-2 Infection: A Case Report

BACKGROUND Since the COVID-19 pandemic, several cases of COVID-19 have been linked to the development of autoimmune disorders, including of the thyroid. Graves' disease (GD) is a rare complication that can occur following SARS-CoV-2 infection. Reports have linked COVID-19 to new onset and exacerbation of GD. We present a case of a 42-year-old woman with a history of GD presenting with impending thyroid storm 3 weeks following a diagnosis of COVID-19. CASE REPORT A 42-year-old woman with a history of GD presented to the Emergency Department (ED) for an acute exacerbation of hyperthyroidism 3 weeks after SARS-CoV-2 infection was diagnosed on a home test. Symptoms included daily headaches, increased bilateral eye pressure, fatigue, muscle weakness, episodes of confusion and agitation, persistent heart palpitations, and goiter. Elevated free T4 of 5.57, free T3 of 15.68, total T3 of 4.43, and near-absent thyroid stimulating hormone were noted. The Burch-Wartofsky scale was 40, which was concerning for an impending thyroid storm; however, at the time of admission, she was not in a thyroid storm. Treatment included propylthiouracil, potassium iodide oral solution, and propranolol, with symptom improvement. Due to prior history of intolerance to antithyroid medications and recent exacerbation, a thyroidectomy was performed once she was in a euthyroid state. CONCLUSIONS Our case demonstrates the importance of recognizing COVID-19 as an etiology or a trigger for new onset or exacerbation of GD. Our case highlights that being vigilant to recognize the association between COVID-19 and thyroid abnormalities for early diagnosis and treatment is imperative.

Site-Specific O-glycosylation of SARS-CoV-2 Spike Protein and Its Impact on Immune and Autoimmune Responses

The world-wide COVID-19 pandemic has promoted a series of alternative vaccination strategies aiming to elicit neutralizing adaptive immunity in the human host. However, restricted efficacies of these vaccines targeting epitopes on the spike (S) protein that is involved in primary viral entry were observed and putatively assigned to viral glycosylation as an effective escape mechanism. Besides the well-recognized N-glycan shield covering SARS-CoV-2 spike (S) proteins, immunization strategies may be hampered by heavy O-glycosylation and variable O-glycosites fluctuating depending on the organ sites of primary infection and those involved in immunization. A further complication associated with viral glycosylation arises from the development of autoimmune antibodies to self-carbohydrates, including O-linked blood group antigens, as structural parts of viral proteins. This outline already emphasizes the importance of viral glycosylation in general and, in particular, highlights the impact of the site-specific O-glycosylation of virions, since this modification is independent of sequons and varies strongly in dependence on cell-specific repertoires of peptidyl-N-acetylgalactosaminyltransferases with their varying site preferences and of glycan core-specific glycosyltransferases. This review summarizes the current knowledge on the viral O-glycosylation of the SARS-CoV-2 spike protein and its impact on virulence and immune modulation in the host.

High risk and low prevalence diseases: Guillain-Barré syndrome

INTRODUCTION

Guillain-Barré syndrome (GBS) is a rare but serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of GBS, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

GBS is a rare immune-mediated neurologic disorder with peripheral nerve injury. It most commonly presents weeks after a bacterial or viral infection, though there are a variety of associated inciting events. The diagnosis is challenging and often subtle, as only 25-30% of patients are diagnosed on their initial healthcare visit. Clinicians should consider GBS in patients with progressive ascending weakness involving the lower extremities associated with hyporeflexia, but the cranial nerves, respiratory system, and autonomic system may be involved. While the ED diagnosis should be based on clinical assessment, further evaluation includes laboratory testing, cerebrospinal fluid (CSF) analysis, and potentially neuroimaging. Not all patients demonstrate albumino-cytological dissociation on CSF testing. Several criteria exist to assist with diagnosis, including the National Institute of Neurological Disorders and Stroke criteria and the Brighton criteria. Management focuses first on assessment of the patient's hemodynamic and respiratory status, which may require emergent intervention. Significant fluctuations in heart rate and blood pressure may occur, and respiratory muscle weakness may result in the need for airway protection. Neurology consultation is recommended, and definitive treatment includes PLEX or IVIG.

CONCLUSIONS

An understanding of GBS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

COVID-19: a modern trigger for Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy

COVID-19 infection has had a profound impact on society. During the initial phase of the pandemic, there were several suggestions that COVID-19 may lead to acute and protracted neurologic sequelae. For example, peripheral neuropathies exhibited distinctive features as compared to those observed in critical care illness. The peripheral nervous system, lacking the protection afforded by the blood-brain barrier, has been a particular site of sequelae and complications subsequent to COVID-19 infection, including Guillain-Barre syndrome, myasthenia gravis, and small fiber neuropathy. We will discuss these disorders in terms of their clinical manifestations, diagnosis, and treatment as well as the pathophysiology in relation to COVID-19.

Clinical Profile, Follow-up, and Role of Neuroimaging in Pediatric Guillain-Barré Syndrome in the COVID Era: An Ambispective Study

Background: To define the varied presentations of Guillain-Barré syndrome in children in the COVID era and 6 months' follow-up outcome. Methods: Ambispective study of 15 months' duration involving children with Guillain-Barré syndrome aged 1 month to 18 years at a tertiary care pediatric hospital. They were categorized into groups A and B based on COVID-19 serology testing. Hughes Disability Scale was used for disability assessment. Modified Rankin scale was used for improvement assessment in follow-up. Results: Of 19 children with Guillain-Barré syndrome, 9 (47%) were females and 10 (53%) were males. Groups A and B had children with negative (8) and positive serology (11), respectively. The most common presentation in both groups was motor weakness. Post-COVID pediatric Guillain-Barré syndrome presented with variants of Guillain-Barré syndrome rather than the classical form (P = .03). In group B, patients with elevated inflammatory markers had poor response to intravenous immunoglobulin, and 5 of 11 patients had good response to pulse steroids, probably depicting an inflammation-predominant pathology. Conclusion: Post-COVID Guillain-Barré syndrome in children presented with Guillain-Barré syndrome variants rather than the classic form. Neuroimaging is of great value in both confirming Guillain-Barré syndrome diagnosis and excluding differentials. Patients with elevated inflammatory markers and residual weakness may be given a pulse steroid trial.