key: cord-0731177-4j7k0261 authors: Lascano, Agustina M.; Epiney, Jean‐Benoît; Coen, Matteo; Serratrice, Jacques; Bernard‐Valnet, Raphaël; Lalive, Patrice H.; Kuntzer, Thierry; Hübers, Annemarie title: SARS‐CoV‐2 and Guillain‐Barré syndrome: AIDP variant with favorable outcome date: 2020-06-01 journal: Eur J Neurol DOI: 10.1111/ene.14368 sha: 8347d19ff86ec01e40e20203310c0a8ca62b8af6 doc_id: 731177 cord_uid: 4j7k0261 The entire world has been experiencing the outbreak of a novel infectious agent known as severe acute respiratory syndrome corona virus 2 (SARS‐CoV‐2), which is responsible for the coronavirus disease 19 (COVID‐19)(1). Life‐threatening complications described in SARS‐CoV‐2 infected patients include acute respiratory distress syndrome, acute kidney failure and cardiac injury(2). Nonetheless, only few neurological complications have been described so far(3). complications described in SARS-CoV-2 infected patients include acute respiratory distress syndrome, acute kidney failure and cardiac injury 2 . Nonetheless, only few neurological complications have been described so far 3 . A recent retrospective study performed in the city of Wuhan, China, reported that 78/214 (36.4%) patients with COVID-19 presented with nervous system clinical findings; mainly dizziness, headache, encephalopathy, stroke, smell and taste disorders and musculoskeletal injury 4 . Zhao and collaborators published the first case of a 61-year-old patient presenting with a rapidly evolving ascending weakness and mild distal sensory complaints, followed by COVID-19 related symptoms, leading to the diagnosis of Guillain-Barré syndrome (GBS) 5 . Authors concluded that SARS-CoV-2 might have triggered GBS in this case, following a para-infectious pattern, as described with Zika virus (ZIKV) infection 6 . A recent series of five GBS cases from northern Italy describes a severe disease course with predominant axonal involvement 7 . We report a series of three cases of typical GBS preceded by classic signs and symptoms of biologically confirmed COVID-19, who were studied in Geneva and Lausanne University Hospitals, Switzerland, between March and April 2020. On April This article is protected by copyright. All rights reserved 12 th , 26'144 COVID-19 cases were confirmed in Switzerland and 9360 in our catchment area. Clinical and ancillary tests description were personally retrieved by the authors, who examined the patients. This report is conducted in compliance to Swiss Federal Act on Research involving Human Beings that wave ethic approval for case report of less than five patients. All patients presented with distal paresthesias and rapidly progressive limb weakness, evolving to either moderate tetraparesis (2/3) Table 1 ). Reverse-transcription polymerasechain-reaction (RT-PCR) assay for SARS-CoV-2 of the CSF was tested in 2/3 patients with a negative result. Initial RT-PCR extracted from the nasopharyngeal swab was positive in two cases. The third case showed a SARS-CoV-2 seroconversion in the serum and the fourth nasopharyngeal swab was positive. This article is protected by copyright. All rights reserved Magnetic resonance imaging was performed in two patients and one disclosed gadolinium enhancement of the lumbosacral roots. Nerve conduction studies (NCS) revealed a typical demyelinating pattern (3/3) and one case showed nerve conduction blocks (supplementary table) , which persisted in an exam conducted one week later. Needle electromyography was recorded in one patient showing no abnormal spontaneous activity. All patients were treated with intravenous immunoglobulins (0.4 g/kg/day for five days). Clinical outcome was favourable in one patient who was dismissed and able to walk without assistance (supplementary material, case 2), another patient was able to walk 100-200 metres with aid (case 3). The third patient remained bedbound but was able to rise from a chair with assistance (case 1). NCS showed a classic demyelinating pattern (AIDP) in the three patients. This observation contrasts with previous publications which reported axonal loss correlating with a more severe disease course and greater disability at one month 7 . In our cohort, full recovery was observed in one patient, another one was able to walk with assistance and the last remained bedridden but was able to rise to standing up (GBS disability score at five weeks follow-up of 1/6, 3/6 and 4/6 respectively). The median period between the onset of COVID-19 related-symptoms and neurological complaints was fifteen days (7-22 days) ; longer than the interval reported by Toscano and collaborators (5-10 days) 7 . In addition, PCR SARS-CoV-2 was not detected in the CSF of our patients nor in the Italian cohort 7 . This article is protected by copyright. All rights reserved These observations support the hypothesis that SARS-CoV-2 triggers GBS via a secondary immune-mediated mechanism rather than a direct viral neuropathic damage, as described after ZIKV infection 6 . Additional clinical data is needed to further elucidate the exact mechanism underlying SARS-CoV-2-associated GBS. A novel coronavirus outbreak of global health concern Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China Neurologic Features in Severe SARS-CoV-2 Infection Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease Guillain-Barre syndrome associated with SARS-CoV-2 infection: causality or coincidence? Guillain-Barre Syndrome Associated with Zika Virus Infection in Colombia Guillain-Barré Syndrome Associated with SARS-CoV-2 Protein level 60 mg/dl White cell count 2 cell/µL Protein level 40 mg/dl; PCR assay for SARS-CoV-2 was not performed White cell count 4 cell/µL Protein level 140 mg/dl Negative PCR assay for SARS-CoV-2 (day 1) Serum studies WBC 8900 cells/mm 3 Lymphocytes 1200 cells/mm 3 Platelets 45500 cells/mm 3 . Normal kidney and liver function Lymphocytes 800 cells/mm 3 Platelets 119000 cells/mm 3 . Normal kidney function. Elevated transaminase levels WBC 4000 cells/mm 3 Lymphocytes 600 cells/mm 3 Platelets 322000 cells/mm 3 . Normal kidney and liver function The authors would like to thank the patients as well as the Service of Internal Medicine from the University Hospitals of Geneva and Lausanne. No targeted funding reported. Coen, Dr. Bernard-Valnet, Dr. Serratrice, and Dr. Hübers have nothing to disclose. The authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary material. This article is protected by copyright. All rights reserved COVID-19 = coronavirus disease 2019; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; RT-PCR = reverse transcription polymerase chain reaction; WBC = white blood cell count; MRI = magnetic resonance imaging; IVIg = intravenous immunoglobulins *Anti-ganglioside antibodies panel includes anti-GM1, GD1a and GQ1b