A 64-year-old man without medical history was admitted to our hospital after he fell and hurt his left shoulder leading to a tear of the rotator cuff. He had fever and cough for two days. In the context of COVID-19 pandemic, SARS-CoV-2 RT-PCR on nasopharyngeal swab was performed and positive. Clinical presentation was moderate with high grade fever for three days requiring oxygen 2–3 L/min through nasal cannula for five days. He received paracetamol, preventing thromboembolism by low molecular weight heparin and lopinavir/ritonavir 400/100 mg twice a day for ten days. Thoracic CT scan showed only 10–25% of ground glass opacities.
Eleven days after the symptom onset, while he did not need oxygen anymore having had no fever for five days, the patient complained of paresthesia in feet and hands. In three days, he installed a flaccid severe tetraparesia. MRC strength evaluation was 2/5 in the legs, 2/5 the arms, 3/5 in the forearms and 4/5 in the hands. Tendon reflexes were abolished in the four limbs. The 128 Hz tuning fork test was negative in the lower limbs and lightly felt in the upper limbs. Facial muscles were normal. The patient complained swallowing disturbance with a risk of suffocation as liquids took the wrong path. The patient was admitted in ICU and mechanically ventilated because of respiratory insufficiency. An intravenous immunoglobulin treatment (0,4 g/kg per day during 5 days) was initiated.
Electrodiagnostic tests five days after neurological symptom onset showed a demyelinating pattern in accordance with Guillain–Barré syndrome (GBS) criteria (Table 1 ) [1]. On needle examination, no rest activity was observed and during muscle contraction, only one single motor unit was recorded with a firing rate up to 25 Hz in the right tibialis anterior, the right vastus lateralis, the left first interosseus and the left deltoideus muscles.
Table 1.
Motor nerve conduction study.
| Nerve | Distal Latency (ms) |
Velocity (m/s) |
Amplitude (mV) |
Conduction Block (%) |
F mini Latency (ms) |
|---|---|---|---|---|---|
| Median R | |||||
| Wrist-APB | 3.69 (N < 4) |
5.9 (N > 4) |
38.7 (N < 30) |
||
| Elbow-wrist |
42.9 (N > 45) |
4.8 | −7.3 | ||
| Ulnar R | |||||
| Wrist-ADM | 3.08 (N < 3.6) |
5.9 (N > 4) |
37.5 (N < 32) |
||
| Below elbow-wrist |
43.4 (N > 45) |
3.9 | −36.2 | ||
| Below elbow-above elbow | 40.6 | 2.5 | −21.6 | ||
| Above elbox-axilla | 54.2 | 2.3 | −9.2 | ||
| Axilla-Erb | 52.8 | 0.14 | −85.1 | ||
| Ulnar L | |||||
| Wrist-ADM | 3.54 (N < 3.6) |
5.0 (N > 4) |
38.7 (N < 32) |
||
| Below elbow-wrist |
44 (N > 45) |
4.3 | −19.3 | ||
| Below elbow-above elbow | 53 | 4 | −10.9 | ||
| Above elbow-axilla | 61.9 | 3.8 | −4.9 | ||
| Axilla-Erb | 45.8 | 0.71 | −79.5 | ||
| Fibular R | |||||
| Ankle-EDB |
7.48 (N < 5) |
1.15 (N > 2) |
No F (N < 52) |
||
| Below fibula-ankle |
26.7 (N > 40) |
0.8 | −29.3 | ||
| Above fibula-below fibula | 37.5 | 0.76 | −12.2 | ||
| Fibular L | |||||
| Ankle-EDB |
5.16 (N < 5) |
1.21 (N > 2) |
No F (N < 52) |
||
| Below fibula-ankle |
27.3 (N > 40) |
0.69 | −14 | ||
| Above fibula-below fibula | 32.4 | 0.5 | −18.6 | ||
| Tibial R | |||||
| Malleolus-FHB |
8.91 (N < 6) |
1.2 (N > 4) |
No F (N < 55) |
||
| Knee-malleolus |
27.7 (N > 40) |
0.79 | −21.4 | ||
| Tibial L | |||||
| Malleolus-FHB |
8.43 (N < 6) |
1.46 (N > 4) |
No F (N < 55) |
||
| Knee-malleolus |
30.5 (N > 40) |
0.69 | −61.1 |
ADM: abductor digiti minimi; APB: abductor pollicis brevis; EDB: extensor digitorum brevis; FHB: flexor hallucis brevis; L: left; N: normal; R: right; Bold: abnormal result according to our laboratory normal values in parenthesis.
On CSF analysis, protein level was 1.66 g per liter and cell count normal. Anti-gangliosides antibodies were absent in the serum. Biological tests were not in favor of a recent infection with Campylobacter jejuni, Mycoplasma pneumoniae, Salmonella enterica, CMV, EBV, HSV1 & 2, VZV, Influenza virus A & B, VIH, and hepatitis E.
COVID-19 pandemic is a worldwide disaster. Pulmonary disorder and respiratory insufficiency are the main problems linked to SARS-CoV-2 infection, which explains difficulties in ICU to treat numerous patients [2]. Recently, Zhao et al. questioned the link between COVID-19 and GBS [3]. Our case is the first GBS with a chronology undoubtedly in favor of a complication of COVID-19 infection. This must be known by clinicians as GBS may lead to ICU admission and needs to be differentiated from a possible ICU-acquired weakness after ICU treatments.
Disclosure of interest
The authors declare that they have no competing interest.
References
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