Guillain-Barré syndrome following SARS-CoV-2 infection in kidney transplant recipient successfully treated with therapeutic plasma exchange.

Dear Editor, Guillain–Barré syndrome (GBS) is post-infectious immune-mediated acute onset polyradiculoneuropathy typically presenting with ascending paralysis and sensory deficits. The diagnosis relies on typical clinical presentation, electrophysiological studies, and cerebrospinal fluid (CSF) examination. Evidence suggests an association between SARS-CoV-2 infection and the development of GBS [1]. We report the first case of GBS after SARSCoV-2 infection in a kidney transplant recipient successfully treated with therapeutic plasma exchange (TPE). A 60-year-old male received a kidney from a deceased donor. Primary graft function was established with no posttransplant complications. Thirteen months after transplantation and 2 months after receiving mRNA vaccine he presented with severe SARS-CoV-2 infection. Fifteen days after the SARS-CoV-2 infection symptoms onset, he presented with ascending leg weakness progressing to tetraparesis. CSF analysis revealed elevated protein levels with normal cell count. Electrophysiological studies were not available to perform due to the limitations of the pandemic setting. Based on clinical presentation and CSF finding GBS was diagnosed. At the time of diagnosis, our country was facing an intravenous immunoglobulin (IVIG) shortage, and the treatment of choice was TPE. The patient was treated with seven courses of TPE, followed by physical therapy. The outcome was complete neurological recovery. Graft function remained stable. GBS usually occurs sporadically. However, evidence suggests increased incidence related to various epidemics worldwide. Numerous case reports and reviews report on GBS related to SARS-CoV-2 infection during the pandemic's peak. Several potential mechanisms are associated with the pathogenesis of GBS after SARS-CoV-2 infection. Present findings suggest post-infectious immune-mediated mechanisms rather than direct induction by the virus [2, 3]. The reported time between SARS-CoV-2 symptoms and GBS onset ranges between 2 and 33 days. The average age of affected patients is 55 years with male predominance. Most of the patients had symptomatic SARS-CoV-2 infection; however, asymptomatic cases were also reported. According to the current data relationship between the severity of the disease and the outcome is unclear. Most patients presented with the classical sensorimotor and demyelining form, although some variants of GBS have also been reported [3]. At the time of diagnosis, our patient was 61 years old, presenting with GBS 15 days after the SARS-CoV-2 infection diagnosis. The ongoing SARS-CoV-2 pandemic forced healthcare systems worldwide to face many challenges and adjust to new realities including shortage of drugs, diagnostic and therapeutical procedures and medical staff. Most reported patients with GBS related to SARS-CoV-2 infection were treated with IVIG, with favorable outcomes in 70% of them [3]. TPE is a treatment option, but in the setting of the COVID pandemic potential problems such as increased risk of hemodynamic instability, removing coagulation factors and exposing staff to COVID should be considered [4]. In a setting of IVIG shortage, which our country was facing at the time of the pandemic peak, our patient was successfully treated with TPE. IVIG treatment is a treatment of choice in immunocompromised kidney transplant recipients with SARS-CoV-2 infection. Regarding IVIG shortage in the SARS-CoV-2 pandemic setting, alternative treatment options should be considered in these patients such as TPE or immunoadsorption, although further studies are needed.