Guillain-Barre Syndrome Related to Coronavirus Disease-2019 (COVID-19) Infection

Guillain-Barre syndrome (GBS) is an acute immune-mediated polyradiculoneuropathy that occurs following a viral or bacterial infection and vaccination. A 61-year-old male with a past medical history significant for hypertension, hyperlipemia, nephrolithiasis, and Coronavirus Disease-2019 (COVID-19) infection 17 days prior presented to the emergency department with complaints of numbness, tingling, and weakness in all four extremities for one day. He endorsed fatigue but denied nausea, vomiting, diarrhea, fever, cough, or shortness of breath. He denied headache, dizziness, vision change, hearing change, speech, or swallowing problems. On examination, he was afebrile with a heart rate of 120 beats/minute, respiratory rate of 18 breaths/minute, blood pressure of 124/98 mm of Hg, and oxygen saturation of 96% while breathing ambient air. He had reduced sensation to light touch in all four extremities. His bilateral upper and lower extremity flexor strength was 4/5. His bilateral upper extremity extensor strength was 3/5. He had bilateral patellar, triceps, and biceps areflexia. He had marked difficulty moving from reclined to sitting position. He was unable to stand. His primary laboratory examination was unremarkable except for mild leukocytosis of 11,400/μL and D-dimer of 3.91 mg/L. A lumbar puncture was performed, revealing one white blood cell, 60 red blood cells, normal glucose, and 97 mg/dL of protein consistent with albumin-cytologic dissociation. His HIV antibody screen and Ganglioside GM antibodies (IgG and IgM) were negative. He had no urge to urinate or bowel movements. His clinical picture was consistent with Guillain-Barre syndrome with evidence of autonomic involvement. Treatment with intravenous immunoglobulin (IVIG) 400 mg/kg daily for five days was initiated. Adequate hydration was maintained to mitigate the risk of thrombosis from IVIG and COVID-19 infection. Negative inspiratory force (NIF) measurements were performed daily and were normal. By day 4 of treatment patient noticed a mild improvement in strength and sensation in all four extremities, and urinary retention resolved. He was discharged to acute care rehab with close neurology follow up. In a recent report of five patients from Italy, the mean day of GBS onset was eight, and none had autonomic symptoms. We report a case of GBS associated with COVID-19 infection with onset at day 17 and the presence of autonomic symptoms like sinus tachycardia, urinary retention and constipation. IVIG or plasma exchange is the mainstay of treatment with similar efficacy. Adequate hydration should be maintained as both IVIG and COVID-19 infection increases the risk of thrombosis.