SARS-CoV-2-Associated
Guillain-Barre Syndrome
is Common but Under-
recognised and Under-
reported

By Josef Finsterer¹, Sinda Zarrouk²

Affiliations

1. Department of Neurol, Neurology and Neurophysiology Center, Vienna, Austria
2. Department of Genetics, University of Tunis El Manar and Genomics Platform, Pasteur Institute of Tunis, Tunis, Tunisia

doi: 10.29271/jcpsp.2023.04.485

Sir,  

We read with interest the valuable paper by Hanif and co-workers about a 32-year-old SARS-CoV-2-positive female, who developed lower limb weakness with reduced tendon reflexes but without any sensory disturbances for 16 days after a positive PCR test for SARS-CoV-2.¹ As work-up for Guillain-Barre syndrome (GBS) revealed demyelinating sensori-motor neuropathy and albuminocytologic dissociation in the cerebro-spinal fluid (CSF), the patient was diagnosed with acute inflammatory demyelinating polyneuropathy (AIDP) and underwent plasmapheresis with a beneficial effect.¹ The study is attractive but has some shortcomings.

We disagree with the message that only a few cases with SARS-CoV-2-associated GBS (SAG) had been published so far. By the end of December 2020, at least 220 SAG cases have been published.² By the end of June 2021, the number of published SAG cases increased to at least 300 [Finsterer, submitted]. Among these 300 SAG patients, age ranged from 7 to 94 years. The male-to-female ratio was 2.18:1. The period between onset of COVID-19 and the onset of SAG ranged between 10 to 90 days. CSF contained SARS-CoV-2 RNA only in one case. GBS subtypes included patients with AIDP (n=171), acute, motor axonal neuropathy (n=24), acute, motor and sensory axonal neuropathy (n=16), Miller-Fisher syndrome (n=8), poly-/mono-neuritis cranialis (n=3), and the pharyngo-cervico-brachial variant (n=1). Treatment included intravenous immunoglobulins (IVIGs, n=241), plasmapheresis (n=28), and steroids (n=7). Artificial ventilation was required in 59 patients. Complete recovery was achieved in 42 patients, partial recovery in 163 patients, and 17 patients died.

Missing is the information whether the CSF tested positive or negative for SARS-CoV-2 RNA. As only two cases were positive for virus RNA in the CSF so far, and only one case for neutralising antibodies,³ and as SAG is an immunological and not an infectious polyradiculitis, one would expect that the CSF in the index patient was negative for SARS-CoV-2 as well.

Also, missing is the discussion about GBS due to SARS-CoV-2 vaccinations. Since the introduction of SARS-CoV-2 vaccinations in December 2020, at least 19 patients with post-vaccination GBS had been reported until the end of June 2021.⁴ These patients were 20 to 86 years old and male-to-female ratio was 0.9:1. Post-vaccination GBS developed in all the patients after the first jab. Fourteen patients received AstraZeneca vaccine, four received the Pfizer vaccine, and one patient received the Johnson vaccine. The time from vaccination to onset of GBS amounted to 3-39 days. The patients received IVIGs (n=13), steroids (n=3), or no therapy (n=3). Mechanical ventilation was indicated in 6 patients. The outcome was poor despite immediate adequate treatment.

In  conclusion,  SAG  is  not  a  rare  condition  and  most  likely under-recognised and under-reported. Not only the virus triggers SAG but also SARS-CoV-2 vaccinations. SAG responds favourably to immediate treatment with IVIGs, plasmapheresis, or steroids. The most effective approach appears to be the zipper concept,⁵ which  relies  on  the  alternate  application  of  IVIGs  and  plasmapheresis.  

COMPETING INTEREST:
The  authors  declared  no  competing  interest.

AUTHORS’ CONTRIBUTION:
JF: Design, literature search, discussion, first draft, and critical comments.
SZ: Literature search, discussion, and critical comments.
All the authors have approved the final version of the manuscript to be published.

REFERENCES

1. Hanif M, Khan AW, Khan MA, Sundas F, Khan SJ. COVID-19-induced guillain-barre syndrome: A rare complication of SARS-CoV-2 infection. J Coll Physicians Surg Pak 2021; 31(7):123-4. doi: 10.29271/jcpsp.2021.Supp2.S123.
2. Finsterer J, Scorza FA. Guillain-barre syndrome in 220 patients with COVID-19. Egypt J Neurol Psychiatr Neurosurg 2021; 57(1):55. doi: 10.1186/s41983-021-00310-7.
3. Araújo NM, Ferreira LC, Dantas DP, Silva DS, Dos Santos CA, Cipolotti R, Martins-Filho PR. First report of SARS-CoV-2 detection in cerebrospinal fluid in a child with guillain-barré syndrome. Pediatr Infect Dis J 2021; 40(7):e274-6. doi: 10. 1097/INF.0000000000003146.
4. Finsterer J, Scorza FA, Scorza CA. Post SARS-CoV-2 vaccination guillain-barre syndrome in 19 patients. Clinics (Sao Paulo) 2021; 76:e3286. doi: 10.6061/clinics/2021/ e3286.
5. Kesici S, Tanyıldız M, Yetimakman F, Bayrakci B. A novel treatment strategy for severe guillain-barré syndrome: Zipper method. J Child Neurol 2019; 34(5):277-83. doi: 10.1177/0883073819826225.