We read with great interest the article by Kaur et al.1 describing the aggressive clinical course in a child with COVID-19–associated transverse myelitis. We would like to share our experience with a child with COVID-19–associated Guillain-Barre syndrome (GBS).
This developmentally normal four-year-old girl presented with a two-day history of pain in the neck, neck floppiness, change in voice, drooling, and bilateral arm weakness. Two weeks before this illness, she had a mild febrile illness without any focus. There was no history of confirmed COVID-19 or COVID-19 vaccination. Examination revealed facial diplegia, bulbar weakness, neck weakness, symmetric proximal-predominant flaccid quadriparesis (upper limb weakness > lower limb), respiratory muscle weakness (requiring mechanical ventilation), and generalized areflexia, without any ophthalmoplegia, encephalopathy, meningism, or other involvement. Inflammatory markers and SARS-CoV-2 polymerase chain reaction were negative. Serum IgG antibodies for SARS-CoV-2 were strongly positive. Nerve conduction study revealed markedly reduced amplitudes, abnormally prolonged distal latencies, and normal conduction velocities in motor nerves with normal sensory study. Cerebrospinal fluid (CSF; day three) showed mildly elevated protein (51 mg/dl, normal: 15-40 mg/dl), while CSF viral panel was negative. Spine magnetic resonance imaging revealed contrast enhancement of the lumbosacral nerve roots (D12 to S1), while brain imaging was normal (Fig ). Considering COVID-19–associated GBS (postinfectious), she was managed with intravenous immunoglobulin (2 g/kg over five days). She responded well and was discharged by day ten (off ventilator, walking with support at discharge).
FIGURE.
Coronal (A) and axial (B) T1-weighted post-contrast magnetic resonance images of the lumbosacral spine showing root enhancement (white arrows).
This report adds to the evolving spectrum of neurological presentations of COVID-19 in children. The literature on COVID-19–associated GBS in children is scarce, with most cases being either demyelinating or motor axonal variants. Although establishing causality with COVID-19 is often difficult, the importance of COVID-19 antibody (IgM and IgG) testing in GBS cannot be understated (when SARS-CoV-2 PCR is negative) especially during the pandemic.2 Descending involvement, as in the index child, is extremely rare in children and has not been described with COVID-19.3 , 4 Hence, this report highlights the importance of being familiar with the wide-ranging heterogenous and atypical presentations of COVID-19.
Footnotes
Author contributions: S.N.M. contributed to the writing of the initial draft of the manuscript, literature search, and patient management. P.M. contributed to analysis of the investigations, critical review and revision of the manuscript. M.S. contributed to patient management and inputs on radiological investigations. All authors approved the final version of the manuscript to be published.
Conflict of interest: The authors have no conflict of interest to disclose regarding this article.
References
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