key: cord-0821859-b3xgp8xz authors: Somkuwar, Anand S.; Shende, Dipti; Arbat, Sameer; Bakamwar, Swapnil title: Guillian–Barre Syndrome in COVID-19 Pregnancy—First Case Report date: 2021-04-17 journal: Ann Indian Acad Neurol DOI: 10.4103/aian.aian_1272_20 sha: 159a699af575ef3e554c5a27e2606b37c7c4bdb3 doc_id: 821859 cord_uid: b3xgp8xz nan Sir, Neurological manifestations of COVID-19 include anosmia, taste disturbances, cerebrovascular strokes and seizures. [1] Guillain-Barre syndrome (GBS) is an autoimmune disorder and occurrence in COVID-19 pregnancy is rare. We reported first case of acute inflammatory demyelinating polyneuropathy (AIDP) variant of GBS in pregnant lady with COVID pneumonia. A 32-year eight-month pregnant lady had headache, tingling in limbs, and mild generalised weakness. When she was tested COVID-19 positive by RT-PCR, she was admitted to our COVID Hospital. Her complete blood count, liver/kidney function test and serum electrolytes were normal. Next day, she underwent emergency ceasarean section because of labour pains. In upper limbs, bilateral median, ulnar CMAPs showed increased latency, conduction block, temporal dispersion, reduced amplitude and conduction velocities. These findings confirmed symmetric demyelinating sensorimotor polyneuropathy favouring AIDP variant of GBS. In next 2 weeks, patient was able to walk. Her newborn was COVID-19 positive but was asymptomatic and recovered after 10 days. COVID-19 commonly manifests with fever and respiratory symptoms but acute cerebrovascular diseases, seizures, ageusia, anosmia, meningitis, encephalitis and skeletal muscle involvement are important neurological manifestations. [1] Recently, case reports of Guillain-Barre in SARS-CoV-2 infection are increasing. [2] The commonly reported clinical features in COVID GBS include limb weakness (tetra paresis, or paraparesis), hypo or areflexia, sensory disturbances, facial palsy, respiratory failure. [2] An association between GBS and coronavirus infections had been reported. [3] Sensorimotor signs, facial palsy, respiratory insufficiency and demyelinating electrophysiological subtype has mentioned GBS with preceding virus infections like Cytomegalovirus and Zika virus. [2] This could be probability in our case. Campylobacter jejuni may be associated with primary axonal subtypes of GBS. [2] The most common electrophysiological pattern observed in COVID GBS was demyelinating. [4] COVID-19 associated GBS should be treated with IVIG unless there is clear contraindication like coagulopathy. [4] GBS is reported in pregnancy. [5] GBS in COVID pregnancy is not yet reported. Intravenous Immunoglobulins 2 gm/kg over 5 days may be safe for GBS with COVID pregnancy. Supportive respiratory care, early tracheostomy, physiotherapy are very important aspects during management. Nil. Dear Editor, Ring chromosome 20 syndrome (R20 syndrome) is a rare chromosomal disorder linked with epilepsy, described as early as 1972 and around 150 such cases have been reported in the existing literature. [1, 2] R20 syndrome is characterized by childhood-onset intractable epilepsy, dysmorphic features, mental disability, behavioural issues and repeated non-convulsive status epilepticus (NCSE). [3, 4] A cytogenetic test is required to confirm the diagnosis. We evaluated a 21-year-old right-handed girl for drug-resistant epilepsy (DRE). Her events started at the age of 10 years. She had recurrent episodes of prolonged behavioural arrest lasting for 30-40 min during which she will be staring in unresponsive state throughout the event. The frequency of these events was 1-3 per day occurring during both awake and sleep. Her prenatal, birth, development and past medical history were unremarkable. She has no family history of epilepsy. Her scholastic performance was poor after the onset of epilepsy. On neuropsychological evaluation, her intelligence quotient (IQ) was 72, indicating borderline intelligence. No behavioural problems were reported. Her general and neurological examination was unremarkable. The magnetic resonance imaging (MRI) was normal and fluorodeoxyglucose-positron emission tomography (FGD-PET) was unremarkable. She underwent long-term video electroencephalogram (EEG) to characterize the events. Many events were recorded. The seizure semiology was characterized by sudden onset of behavioral arrest with prolonged staring and immobile upper and lower extremities for 30-40 min associated with bilateral eye blinking. She was unresponsive to response testing throughout the event. Interictal EEG recording showed bi-frontal spike and sharp wave discharges [ Figure 1a ]. Ictal EEG recordings showed bi-frontal slow spike and wave discharges of 3-4 Hz frequency for 1-2 min followed by 5-6 Hz bifrontal spike and wave discharges which consistently evolved in frequency and amplitude for the next 30-40 min without any clear cut offset. The total duration of paroxysms was >40% of the recording length [ Figure 1b ]. A possibility of R20 syndrome was considered based on the above findings. To confirm the diagnosis, a chromosomal analysis of 30 lymphocytes was completed, which revealed a female karyotype with a translocation involving chromosome 1 and chromosome 12 along with a ring chromosome 20 in the mosaic condition in 14 of the 25 metaphases (56%) -46, XX, t (1;12)(q21;q11), mos r(20) [ Figure 2 ]. Translocation involving chromosome 1 and 12 had not been linked to Epilepsy. Previous treatment with valproic acid, oxcarbazepine and clobazam had no beneficial effect in reducing her seizure frequency. She was started on Valproic acid and Lamotrigine. At one year follow up, she had a significant reduction in seizure frequency with a frequency of 1-2 episodes per month. Neurologic manifestations of hospitalized patients with coronavirus disease Guillain-Barré syndrome in SARS-CoV-2 infection: An instant systematic review of the first six months of pandemic Neurological complications during treatment of Middle East respiratory syndrome COVID-19-associated Guillain-Barré syndrome: The early pandemic experience Guillain-Barré syndrome in pregnancy: A conservatively managed case