(P49) Rare Sensory Variant Guillain-barré Syndrome Secondary to sars-cov-2 Infection

Chief Complaint : Ascending bilateral arm and leg paresthesias with difficulty ambulating

History of Present Illness : A 44 year-old male with past medical history of hypertension, hyperlipidemia and pre-diabetes presented to the Emergency Department with 3 weeks of paresthesias of the bilateral arms and legs along with increasing difficulty ambulating. The paresthesias began in the bilateral hands but spread symmetrically to his knees and elbows three days prior to presentation. He also reported gait instability secondary to feeling off-balance.

No accompanying fever, chills, weakness, headache, rhinorrhea, congestion, cough, neck pain, blurred vision, double vision or difficulty swallowing.

He works on a farm but denies any exposure to pesticide or chemical agents. No recent trauma. No recent illnesses. No recent foreign travel. No drug or alcohol use.

He was seen 5 days prior with normal labs including CBC, CMP, B12, folate, urinalysis and syphilis testing. He was discharged with presumptive diagnosis of peripheral neuropathy.

Pertinent Physical Exam: Awake, alert and oriented. Skin warm, dry and intact without rashes or lesions. Visual fields full to confrontation. Extraocular motions intact. Pupils equal, reactive to light. No nystagmus or ocular clonus. Regular rate and rhythm. Lungs clear to auscultation. Abdomen soft, non-tender. Muscle strength 5/5 bilateral upper and lower extremities. No tremor, asterixis or myoclonus. Decreased sensation to light touch and pinprick bilaterally up to the knee and elbow. 2+ DTRs throughout except for absent bilateral ankle jerk. Positive Romberg. Normal finger-to-noses and heel-to-shin. Patient is able to stand at the bedside but takes wide-based, cautious steps.

Pertinent Laboratory Data: WBC- 9.4, Hgb-15.7, Hct-47.4, Plt-204, Na-139, K-4.9, Cl-104, HCO3- 24, Glu-93, BUN-21, Cr-0.8, TSH- 0.49

COVD 19-positive

CSF studies: appearance- clear, WBC- 1, RBC- 82, Total Protein- 202, Glucose-46, Extended viral panel- negative, Culture- no growth

Case Discussion: Here, we present a rare case of sensory variant Guillain-Barre syndrome (GBS) thought to be secondary to asymptomatic COVID-19 infection.

GBS is an immune-mediated polyradiculopathy that is often associated with a preceding illness. It typically manifests with ascending paralysis and sensory loss. However, many variants and subtypes exist. The pure sensory variant of GBS is an acute, monophasic illness with exclusive sensory signs and symptoms in the absence of systemic disorders that may cause an acute peripheral neuropathy. It is thought to be caused by acute demyelination of the peripheral sensory nerves. Although universal diagnostic criteria are lacking, the pure sensory variant makes up roughly one percent of GBS cases. The low number of case reports is thought to be partially due to the fact that most cases with predominant sensory symptoms manifest some weakness.

Severe acute respiratory syndrome (SARS-CoV-2) has been shown to be associated with a variety of central and peripheral neurologic manifestations. GBS is one such complication documented in several case series. The associated mechanism is unclear but thought to be mediated by a dysregulated inflammatory response. Neurologic symptoms are believed to manifest 2-4 weeks after viral infection.

The patient in this case was started on intravenous immunoglobulin (IVIG) in the emergency department after cerebrospinal studies showed cytoalbuminologic dissociation consistent with GBS. He was admitted to the hospital under the supervision of neurology and discharged after receiving a 5 day course of IVIG with marked improvement in symptoms.

References and Acknowledgements (Optional): -Uncini A, Yuki N. Sensory Guillain-Barré syndrome and related disorders: an attempt at systematization. Muscle Nerve. 2012; 45 (4):464-470.
-Raid K, Aldabbour B, Aljewazi M. A Rare Case with New Insights: Pure Sensory Guillain Barre Syndrome with Axonal Features. International Medical Case Reports Journal. 2020: 13; 543-549.
-Luijten et al. Guillain-Barré syndrome after SARS-CoV-2 infection in an international prospective cohort study. Brain. 2021. 144: 3392-3404.
-Khan F, et al. COVID-19 associated Guillain-Barré syndrome: post infectious alone or neuroinvasive too? J Med Virol. 2021. 93 (10): 6045-6049.