25 September 2024
: Case report 
Complex Interplay of COVID-19 ARDS with Guillain-Barré Syndrome and Cerebral Infarction: A Case Study
Unusual clinical course, Challenging differential diagnosis
Daiki Morikawa1A, Shigeki Fujitani1AE*, Tomoyuki Shirahige
1A, Yuta Hagiwara2A, Kenichiro Morisawa1A, Toru Yoshida1A
DOI: 10.12659/AJCR.944390
Am J Case Rep 2024; 25:e944390
Table 1. Clinical characteristics, tests, treatment, and outcome of reported Guillain-Barré syndrome associated with SARS-CoV-2 infection with mechanical ventilation.
| No. | Country | Age | Sex | Severity of PMH | COVID-19 Mild: 0Severe: 1Critical: 2 | V-V ECMO | Hughes Functional Grade of GBS | Diagnostic method of GBS | Time from COVID-19 symptom onset to GBS symptom onset (d) | Time from neurological illness onset to nadir (d) |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 (7) | Italy | 55 | M | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 10 | 2 |
| 2 (7) | Italy | 61 | M | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 7 | 4 |
| 3 (7) | UK | 42 | M | NA | mild | – | 2 – able to walk 5m (across an open space) but incapable of manual work/running | Neurological findings, albuminocytologic dissociation, EDX | 13 | NA |
| 4 (7) | UK | 60 | M | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | −1 | NA |
| 5 (7) | Italy | 70 | F | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 23 | 5 |
| 6 (7) | USA | 54 | M | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings | 8 | 2 |
| 7 (7) | Italy | 71 | M | HTN, AAA, lung cancer | Critical | – | 6 – dead | Neurological findings, albuminocytologic dissociation, EDX | A few days | 4 |
| 8 (7) | France | 64 | M | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 11 | 3 |
| 9 (7) | Italy | 66 | F | HTN | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 10 | 3 |
| 10 (8) | JAPAN | 69 | M | DM | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation | 24 | 4 |
| 11 (9) | Chile | 31 | F | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, EDX | 10 | 1 |
| 12 (10) | USA | 36 | M | HTN, reanal transplants | Critical | v | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation | 22 | 2 |
| 13 (11) | USA | 62 | F | NA | mild | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation | A few days | 1 |
| 14 (12) | USA | 69 | M | Chronic myelogenous leukemia, HTN, coronary, artery disease | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 35 | 2 |
| 15 (13) | France | 53 | M | BPPV, asthma | Mild | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 22 | 3 |
| 16 (13) | France | 68 | F | Localized scleroderma | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, EDX | 32 | 22 |
| 17 (13) | France | 78 | F | Af, hypothyroidism, depressive disorder, herniated disk | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 24 | 18 |
| 18 (14) | Syria | 55 | M | NA | Critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 4 | 3 |
| 19 (15) | USA | 59 | F | HTN, hyperlipidemia, cerebral vascular accident, DM | Critical | – | 6 – dead | Neurological findings, albuminocytologic dissociation | 20 | 2 |
| 20 (16) | Iran | 38 | M | NA | critical | – | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, EDX | 11 | 3 |
| 20 (16) | UK | 57 | M | HTN, psoriasis | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation | 6 | 2 | ||
| 21 | JAPAN | 55 | M | UC, DLP, HTN | Critical | + | 5 – requiring assisted ventilation (for any part of the day or night) | Neurological findings, albuminocytologic dissociation, EDX | 57 | 2 |
| AAA – abdominal aortic aneurysm; AIDP – acute inflammatory demyelinating polyneuropathy; AMAN – acute motor axonal neuropathy; COVID-19 – coronavirus disease 2019; d – days; DLP – dyslipidemia; DM – diabetes mellitus; EDX – electrophysiological; F – female; GBS – Guillain-Barré syndrome; HTN – hypertension; ICU – Intensive Care Unit; IVIg – intravenous immunoglobulin; LL – lower limbs; M – male; MRC – Medical Research Council scale; MRI – magnetic resonance imaging; NA – not applicable; NP – not performed; PEx – plasma exchange; PMH – past medical history; UC – ulcerative colitis; UL – upper limbs; V-V ECMO – veno-venous extracorporeal membrane oxygenation. | ||||||||||
| No. | MRC | GBS clinical subtype | Cranial nerve involvement | Facial palsy (unilateral or bilateral) | Brighton criteria level | Initial neurological symptoms | Protein in Key neurological signs | CSF (mg/dL) | Cell in CSF (/mm3) | |
| 1 (7) | NA | Typical | Facial weakness evolving to areflexia/diplegia | Positive | 1 | Paresthesia in the four limbs and lower limb weakness | Flaccid tetraparesis and facial weakness evolving to areflexia and respiratory failure | 193 | 0 | |
| 2 (7) | NA | Typical | Facial weakness and dysphagia | Positive | 1 | Asthenia | Facial weakness, flaccid areflexic paraplegia, and respiratory failure | 40 | 3 | |
| 3 (7) | NA | Typical | Dysphagia | Negative | 2 | Distal limb numbness and weakness; dysphagia | Quadriparesis; areflexia; sensory loss | 50 | 3 | |
| 4 (7) | NA | Typical | Facial and bulbar weakness | Negative | 2 | Distal limb numbness and weakness | Quadriparesis; areflexia; sensory loss; dysautonomia; facial and bulbar weakness | 60 | 2 | |
| 5 (7) | 4/5 UL and LL | Typical | Negative | Negative | 1 | Asthenia, hands and feet paresthesia and gait difficulties | Polyradiculoneuropathy with predominant demyelination of both motor and sensory fibers, sural sparing pattern | 48 | 1 | |
| 6 (7) | 2/5 UL and LL | Typical | Negative | Negative | 3 | Numbness and weakness of his lower extremities | Absent lower extremity deep tendon reflexes along with decreased lower extremity strength compared to upper extremities. | Not performed | Not performed | |
| 7 (7) | 3/5 UL, 2/5 LL | Typical | Negative | Negative | 1 | Paresthesia at limb extremities | Paresthesia at limb extremities | 54 | 9 | |
| 8 (7) | 2/5 arms, 3/5 forearms, 4/5 hands, 2/5 LL | Typical | Swallowing disturbance | Negative | 1 | Paresthesia in feet and hands | Paresthesia in feet and hands and swallowing disturbance | 166 | 0 | |
| 9 (7) | 4/5 distal muscle, UL | Typical | Positive | Unilateral | 1 | Weakness in LL | Proximal weakness in all limbs, dysesthesia, and unilateral facial palsy | 108 | 0 | |
| 10 (8) | Mild muscle weakness | Typical | A loss of cough reflex | Negative | 1 | A loss of cough reflex | Diminished tendon reflexes, mild muscle weakness | 202 | 1 | |
| 11 (9) | 1/1 UL, 1/1 LL | Typical | Facial diplegia, tongue paresis | Positive | 1 | Paresthesia at all limb extremities | Paresthesia at limb extremities | 1,8 | 5 | |
| 12 (10) | 4/5 UL, 3/5 LL | Typical | Negative | Negative | 1 | Numbness tingling over his fingers, toes, and perioral region | Paresthesia in feet | 117 | 1 | |
| 13 (11) | 4/4 UL, 4/4 LL | Typical | Positive | Positive | 1 | Progressive weakness and numbness in bilateral lower extremities | Flaccid tetraparesis and facial weakness evolving to areflexia and respiratory failure | 587 | 4 | |
| 14 (12) | 1/1 UL, 1/1 LL | Typical | Negative | Negative | 1 | Paresthesia at all limb extremities | Flaccid tetraparesis and respiratory failure | 92,8 | 9 | |
| 15 (13) | 1/1 UL, 1/1 LL | Typical | Negative | Negative | 1 | Painful tetraparesis, sensory impairment | Areflexia in lower limbs, Hyporeflexia in upper limbs | 1,7 | 2 | |
| 16 (13) | 1/1 UL, 1/1 LL | Typical | Positive | Positive | 1 | Flaccid tetraplegia | Flaccid tetraplegia and external ophthalmoplegia | 0,23 | 2 | |
| 17 (13) | 1/1 UL, 1/1 LL | Typical | Positive | Positive | 1 | Flaccid tetraplegia | Flaccid tetraplegia and facial diplegia | 3,31 | 2 | |
| 18 (14) | 2/5 UL, 2/5 LL | Typical | Negarive | Negative | 1 | lower extremities weakness | Flaccid tetraplegia and facial diplegia | 325 | 0 | |
| 19 (15) | 1/1 UL, 1/1 LL | Typical | Negative | Negative | 1 | Flaccid tetraplegia | Flaccid tetraplegia | 50 | 1 | |
| 20 (16) | 4/5 UL, 2/5 LL | Typical | Positive | Positive | 1 | Parethesia of his hands and feet | Facial weakness, flaccid areflexic paraplegia, and respiratory failure | Not performed | Not performed | |
| 20 (16) | 4/5 UL, 4/5 LL | Typical | positive | positive | 1 | Difficulty standing unaided and noticed some tingling sensation in his feet | Flaccid tetraplegia | 0,51 | 1 | |
| 21 | 0/5 UL and LL | Typical | positive | bilateral | 1 | Complete quatriplegia | Bilaretal facial palsy quadplasia | 124 | 0 | |
| AAA – abdominal aortic aneurysm; AIDP – acute inflammatory demyelinating polyneuropathy; AMAN – acute motor axonal neuropathy; COVID-19 – coronavirus disease 2019; d – days; DLP – dyslipidemia; DM – diabetes mellitus; EDX – electrophysiological; F – female; GBS – Guillain-Barré syndrome; HTN – hypertension; ICU – Intensive Care Unit; IVIg – intravenous immunoglobulin; LL – lower limbs; M – male; MRC – Medical Research Council scale; MRI – magnetic resonance imaging; NA – not applicable; NP – not performed; PEx – plasma exchange; PMH – past medical history; UC – ulcerative colitis; UL – upper limbs; V-V ECMO – veno-venous extracorporeal membrane oxygenation. | ||||||||||
| No. | PCR assay of SARSCoV-2 on CSF | EDX subtype | Antigan-glioside antibodies | MRI (Head) | MRI (Spine) | IVIG | PEx | |||
| 1 (7) | Negative | AMAN | Negative | Normal | Enhanced of caudal nerve root | + | – | |||
| 2 (7) | Negative | AIDP | Negative | NP | normal | + | + | |||
| 3 (7) | Not performed | AIDP | NP | NP | Not performed | + | – | |||
| 4 (7) | Not performed | AIDP | NP | normal | Not performed | + | – | |||
| 5 (7) | Not performed | AIDP | NP | NP | Not performed | + | – | |||
| 6 (7) | Not performed | NP | NP | NP | Normal | + | – | |||
| 7 (7) | Negative | AIDP | NP | NP | Not performed | + | – | |||
| 8 (7) | Not performed | AIDP | Negative | NP | 2 | + | – | |||
| 9 (7) | Negative | AIDP | Negative | NP | Not performed | + | – | |||
| 10 (8) | Not performed | AIDP | Positive | NP | Not performed | + | v | |||
| 11 (9) | Not performed | AIDP | NP | NP | Not performed | + | – | |||
| 12 (10) | Not performed | AIDP | NP | normal | Not performed | + | + | |||
| 13 (11) | Not performed | NP | NP | normal | Not perfomed | + | – | |||
| 14 (12) | Not performed | AIDP | NP | NP | Not performed | + | – | |||
| 15 (13) | Not performed | AIDP | Positive | NP | Not performed | + | – | |||
| 16 (13) | Not performed | Miller Fisher syndrome with involvement of the peripheral nerves | Negtive | NP | Not performed | + | – | |||
| 17 (13) | Not performed | AIDP | Negative | Leukoencephalopathy, cortical/subcortical brain atrophy | Not performed | + | – | |||
| 18 (14) | Not performed | AMAN | NP | NP | Not perfomed | – | + | |||
| 19 (15) | Not performed | NP | Negative | NP | Not performed | + | – | |||
| 20 (16) | Not performed | AIDP | NP | NP | Not performed | - | + | |||
| 20 (16) | Not performed | AIDP | NP | NP | Not peformed | + | – | |||
| 21 | Negative | AMAN | Positive | Multiple cerebral infarction | Normal | + | – | |||
| AAA – abdominal aortic aneurysm; AIDP – acute inflammatory demyelinating polyneuropathy; AMAN – acute motor axonal neuropathy; COVID-19 – coronavirus disease 2019; d – days; DLP – dyslipidemia; DM – diabetes mellitus; EDX – electrophysiological; F – female; GBS – Guillain-Barré syndrome; HTN – hypertension; ICU – Intensive Care Unit; IVIg – intravenous immunoglobulin; LL – lower limbs; M – male; MRC – Medical Research Council scale; MRI – magnetic resonance imaging; NA – not applicable; NP – not performed; PEx – plasma exchange; PMH – past medical history; UC – ulcerative colitis; UL – upper limbs; V-V ECMO – veno-venous extracorporeal membrane oxygenation. | ||||||||||
| No. | Diagnostic SARS-CoV-2 testing | Screening for other infective agents | Another reported treatment | Systemic steroid | Outcome | |||||
| 1 (7) | nasopharyngeal swab was positive for SARS-Cov-2 (not mentioned RT-PCR or other) | NA | Azithromycin | – | Poor outcome, still in ICU owing to neuromuscular respiratory failure and flaccid tetraplegia. | |||||
| 2 (7) | Positive SARS-CoV-2 IgG | , EBV, CMV, HSV, VZV, influenza, HIV (all were negative) | NA | – | Mechanical ventilation through tracheostomy. | |||||
| 3 (7) | Positive nasal-pharyngeal throat SARS-CoV-2 PCR test | no | NA | – | NA | |||||
| 4 (7) | Positive nasal-pharyngeal throat SARS-CoV-2 PCR test | no | NA | – | NA | |||||
| 5 (7) | Positive for SARS-CoV-2-RNA on RT-PCR with a nasopharyngeal swab | and Cytomegalovirus (CMV) serology (IgM and IgG), and CSF: herpes simplex virus, varicella zoster virus, Epstein-Bar virus, CMV, HIV-1, IgM and IgG) | NA | – | NA | |||||
| 6 (7) | Specimen; SARS-CoV-2 test (not clearly mentioned the detail) | Espiratory viral panel testing (nasopharyngeal PCR): Rhinovirus (+) | Hydroxychloroquine | – | Clinical course showed improvement in his respiratory status with liberation from mechanical ventilation on day 4 of IVIG therapy | |||||
| 7 (7) | Nasopharyngeal swab was positive for SARS-Cov-2 (not mentioned RT-PCR or other) | NA | Hydroxychloroquine | – | Died because of progressive respiratory failure | |||||
| 8 (7) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | , , , CMV, EBV, HSV1 & 2, VZV, Influenza virus A & B, VIH, and hepatitis E (all were negative) | NA | – | NA | |||||
| 9 (7) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | NA | Hydroxychloroquine | – | IVIg was ineffective | |||||
| 10 (8) | Positive for SARS-CoV-2-RNA on RT-PCR with sputum sample | NA | Hydroxychloroquine | – | Clinical course showed improvement in his respiratory status with liberation from mechanical ventilation on day 5 of IVIG therapy | |||||
| 11 (9) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | NA | NA | – | Clinical course showed improvement on day 5 of IVIG therapy | |||||
| 12 (10) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | NA | NA | + | Clinical course showed improvement in his respiratory status with liberation from mechanical ventilation | |||||
| 13 (11) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | NA | NA | + | Clinical course showed improvement in his respiratory status with liberation from mechanical ventilation | |||||
| 14 (12) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | NA | NA | + | Clinical course showed improvement in his respiratory status with liberation from mechanical ventilation | |||||
| 15 (13) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | , EBV, HBV, HCV, HEV, HIV (all were negative), CMV IgG positive, IgM positive | NA | – | Sensory impairment of sole, balance disorder | |||||
| 16 (13) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | NA | Hydroxychloroquine, azithromycin, Atazanavir/ritonavvir | – | Complete recovery | |||||
| 17 (13) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | EBV, HBV, HCV, HEV, HIV, M pneumoniae(all negative) | Dexamethasone | + | Weakness in lower limbs, balance disorder | |||||
| 18 (14) | serum COVID-19 antibodies | NA | NA | – | Clinical course showed improvement in his respiratory status with liberation from mechanical ventilation and improvement in his muscles weakness | |||||
| 19 (15) | Positive for SARS-CoV-2 on RT-PCR with nasopharyngeal swab | NA | Dexamethasone | + | Died | |||||
| 20 (16) | Negative | NA | Dexamethasone | + | Complete recovery | |||||
| 20 (16) | Negative | NA | NA | – | Clinical course showed improvement in his respiratory status with liberation from mechanical ventilation | |||||
| 21 | Positive nasal-pharyngeal throat SARS-CoV-2 PCR test | , and ,HIV, EBV, Syphilis, Tuberculosis CSF: bacteria, Cryptococcus, CVM (all negative) | Ciclesonide, Favipiravir and methylprednisolone | + | Mechanical ventilation through tracheostomy | |||||
| AAA – abdominal aortic aneurysm; AIDP – acute inflammatory demyelinating polyneuropathy; AMAN – acute motor axonal neuropathy; COVID-19 – coronavirus disease 2019; d – days; DLP – dyslipidemia; DM – diabetes mellitus; EDX – electrophysiological; F – female; GBS – Guillain-Barré syndrome; HTN – hypertension; ICU – Intensive Care Unit; IVIg – intravenous immunoglobulin; LL – lower limbs; M – male; MRC – Medical Research Council scale; MRI – magnetic resonance imaging; NA – not applicable; NP – not performed; PEx – plasma exchange; PMH – past medical history; UC – ulcerative colitis; UL – upper limbs; V-V ECMO – veno-venous extracorporeal membrane oxygenation. | ||||||||||