Letter to the Editor
We were excited to read the article by Sharma et al. on a 27 years-old male diagnosed with SARS-CoV-2 associated Guillain-Barre syndrome (GBS) subtype acute, inflammatory demyelinating polyneuropathy (AIDP), two weeks after suspected infection with SARS-CoV-2 [1]. The patient partially recovered on intravenous immunoglobulins (IVIGs) at discharge three weeks after admission [1]. It was concluded that patients with tingling sensations, paresthesia, and difficulty walking associated with COVID-19 symptoms should not be misdiagnosed as arthralgia or myalgia, but GBS should be considered as a rare but serious complication of SARS-CoV-2 [1]. The study is appealing but raises concerns that need to be discussed.
The patient had complained of a dry cough for 2 weeks prior to admission, but clinical lung examination and chest X-ray were unremarkable [1]. No explanation for this discrepancy was given. Although D-dimer was normal, pulmonary embolism should have been ruled out by perfusion CT of the lungs. Since WBC counts, C-reactive protein, D-dimer, and ferritin levels were within normal limits and no fever was described [1], it is quite unlikely that the patient had pneumonia, pleuritis, or bronchitis. We should be informed rmed how the involvement of the respiratory muscles in GBS has been ruled out. Particularly we should know whether needle electromyography (EMG) of the axial muscles and nerve conduction studies (NCSs) of the phrenic nerve were within normal limits. The results of arterial blood gas analysis (BGA) and the results of lung function tests are also decisive, especially if the vital capacity (VC) was normal or reduced. Given that respiratory symptoms had improved upon discharge [1], we should know whether this description refers to the initial cough or to respiratory symptoms newly appearing during hospitalization.
Another cause of the cough that has not been considered a differential etiology is cardiac involvement in the SARS-CoV-2 infection. Cardiac involvement in SARS-CoV-2 includes myocarditis, heart failure, acute coronary syndrome, and arrhythmias [2,3]. We should be informed if the index patient complained about cardiac symptoms other than coughings, such as exertional dyspnoea, neck vein distension, or leg edema. Regarding the elevated creatine-kinase (CK), we should be informed whether the elevated CK levels are from the brain, muscle or heart. CK can be elevated, particularly in patients with myocarditis, a common complication of SARS-CoV-2 infections [4]. We should be told if CK-MB, troponin, and pro-brain-natriuretic peptide (pro-BNP) were also elevated. We should also know the results of transthoracic echocardiography and whether Takotsubo syndrome (TTS) has been ruled out as the cause of the cough. TTS has been repeatedly reported as a complication of SARS-CoV-2 infections [5], mimics myocardial infarction but may only manifest with respiratory symptoms and elevated CK. Were the routine electrocardiography leads all normal? After how many days did the CK return to normal?
Overall, the interesting report has several limitations which challenge the results and their interpretation. Clarifying these shortcomings would strengthen the conclusions and could improve the value of the study. In patients with GBS and respiratory symptoms, affection of the respiratory muscles in polyradiculitis needs to be thoroughly ruled not to miss the point at which these patients require ventilator support.
Ethics approval
Was in accordance with ethical guidelines. The study was approved by the institutional review board.
Funding sources
No funding was received.
Author contribution
Author: design, literature search, discussion, first draft, critical comments, final approval.
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Guarantor
Josef finsterer.
Consent to participate
Was obtained from the patient.
Consent for publication
Was obtained from the patient.
Availability of data
All data are available from the corresponding author.
Code availability
Not applicable.
Consent
Not applicable.
Declaration of competing interest
None.
Acknowledgement
None.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data are available from the corresponding author.