Case Presentation: A 38-year-old female with a history of generalized anxiety disorder and recent COVID-19 infection presented with ascending parasthesias. Two weeks prior to admission, she developed a fever and sore throat. She subsequently tested positive for COVID-19. Four days after her symptoms began she developed bilateral numbness and tingling in her feet which progressed in ascending pattern to her abdomen. She then also noticed right posterior upper arm numbness prompting hospital evaluation. Her vital signs were unremarkable. Physical exam showed diminished sensation in the lower extremities, as well as loss of sensation on the right arm in the T1 dermatome. Strength exam of lower extremities was normal. She was able to rise from seated position and stand with normal base but did have an unsteady gait. Laboratory workup was unremarkable with normal CBC, BMP, cardiac markers, TSH, A1c, B12, SPEP and RPR. A lumbar puncture was performed and revealed mildly elevated protein (50 mg/dL) without pleocytosis, and an unremarkable glucose level. MRI spine did not show any abnormalities. EMG/NCS also conducted inpatient and was unremarkable. Neurology was consulted and given constellation of symptoms, the patient was diagnosed with Guillain-Barre Syndrome due to recent COVID-19 infection. She received 5 days of IVIG with improvement in her symptoms. She regained partial sensation in her upper and lower extremities. She was discharged to follow up with outpatient neurology. Since discharge from the hospital, she has continued to have improvements in her sensation.
Discussion: Guillain- Barre Syndrome (GBS) is a rare immune-mediated disease of the peripheral nervous system that is usually triggered by infections. The immune response to the recent infection triggers an attack on the peripheral nerves via molecular mimicry. Patients with GBS classically present with symmetrical weakness in lower extremities that ascends to the upper extremities. Presentation may vary as motor, sensory, cranial, and sympathetic nerves can be affected. Diagnosis involves history, neurologic examination, and CSF studies (1). As in our case, CSF studies can show elevated protein and normal cell count, though protein can be normal in 30-50% of cases. GBS due to COVID-19 is similar in presentation compared to GBS in non-COVID illness (3). GBS is the most commonly reported neuromuscular manifestation of COVID-19 infections, (2). Typically, in these cases, patients initially have respiratory symptoms consistent with COVID-19 infection with the symptoms of GBS developing on average within the following two weeks after onset of respiratory symptoms. GBS secondary to other infections also typically develops around two weeks after infection (4). Treatment of GBS in both COVID and non-COVID patients involves IVIG or plasma exchange. IVIG is more commonly used due to availability.
Conclusions: Although GBS usually presents with ascending motor symptoms, sensory variant GBS has been described. In patients presenting with ascending neurologic symptoms and recent viral illness including COVID-19, GBS is an important diagnosis to consider.