COVID-19, Neurology

Acute Inflammatory Demyelinating Polyneuropathy After COVID-19

A 49-year-old male with no significant past medical history presented to the emergency department reporting generalized weakness, with lower extremities weaker than upper extremities and bilateral facial numbness.

The patient had multiple falls without loss of consciousness or head trauma and described lower extremity weakness that had progressed to his upper extremities. He denied recent fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, or abdominal pain. He also denied recent travel. His symptoms began after having COVID-19 in November 2020, two months prior to his ED visit.

The patient’s physical exam was pertinent for bilateral partial facial nerve palsies, bilateral weakness of the lower extremities, inability to lift against gravity, with bilateral reduced patellar reflexes. The patient also demonstrated bilateral proximal upper extremity weakness, momentarily able to lift both arms against gravity followed by bilateral downward drift.

The patient had unremarkable CT head, CTA head and neck, CBC, and CMP, but had an elevated ESR, CRP, and CK. Due to concern for post-COVID myositis or Guillain-Barré syndrome (GBS), the patient was admitted to neurology for further workup. The patient’s EMG/NCS was supportive of a subtype of GBS known as acute inflammatory demyelinating polyneuropathy (AIDP), then confirmed by lumbar puncture. Further workup included multiple sclerosis panel with elevated IgG index and positive oligoclonal bands, unremarkable flow cytometry, and negative ganglioside antibody panel. The patient started plasmapheresis and intravenous immunoglobulin. Overall improvement was seen in the patient’s global weakness after IVIG and plasmapheresis. The patient was later discharged with outpatient physical therapy.

Discussion
GBS is an acute immune-mediated polyneuropathy and is one of the most common causes of acquired weakness often provoked by an antecedent infection.1 Campylobacter jejuni gastroenteritis and upper respiratory infection are the most common triggers of GBS. Since the COVID-19 outbreak in 2020, COVID-19 has been known to cause a myriad of post-infection complications such as stroke and encephalopathy, and multiple cases of GBS/AIDP have been reported in the literature.2,3 Although post COVID-19 fatigue and weakness are common and often benign complaints, high suspicion for GBS should be upheld when evaluating these patients.

 


References

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