Recurrent GBS With COVID-19 in a Child: A Case Report

To the Editors:

Severe acute respiratory syndrome coronavirus 2 causes coronavirus disease 2019 (COVID-19), which is associated with a wide range of neurological disorders, including Guillain–Barré syndrome (GBS).¹ The GBS is an acute polyradiculoneuropathy leading to flaccid paresis in which approximately two-thirds of patients report a preceding infection, such as diarrhea or an upper respiratory tract infection. GBS is generally considered monophasic, but recurrences occur in a presently undefined subgroup of patients.² To the best of our knowledge, this is the first pediatric case, of recurrent GBS associated with COVID-19.

In 2020, A male patient, then 6 years of age, was admitted to our hospital’s pediatric intensive care unit with symmetric ascending paralysis with severe acute respiratory syndrome coronavirus 2 real-time reverse transcription polymerase chain reaction positivity. Neurological examination revealed bilateral lower and upper limb flaccid weakness of 1/5 affecting the proximal and distal muscles, with absent deep tendon reflexes and weakness of the neck flexor and extensor muscles. The patient had severe respiratory muscle weakness and required invasive mechanical ventilation. Based on spinal magnetic resonance imaging, cerebrospinal fluid parameters, and electrophysiological study, acute motor axonal neuropathy associated with COVID-19 was diagnosed, and he was promptly treated with therapeutic plasma exchange, intravenous immunoglobulin, and methylprednisolone. He was discharged after 2 months and fully recovered within 1 year. The patient had been able to perform activities, such as walking, running, swimming, and cycling for the past year.

In 2022, at age 8, the patient presented with fever and lower limb paralysis to our hospital. Neurological examination revealed distal weakness equally with absent deep tendon reflexes in lower limbs. Cerebrospinal fluid analysis and other laboratory findings are shown in Table 1. Electrophysiology studies showed features consistent with acute demyelinating polyneuropathy and confirmed the diagnosis. Brain and spinal magnetic resonance imaging were normal. Ganglioside panel included GM1, GQ1b, GD1b, GD1a, GM3 and GM2 were negative. Infections that were more commonly predisposed to GBS were negative. A course of intravenous immunoglobulin (0.4 g/kg for 5 days) prompted gradual progressive functional recovery. On day 12, he was discharged from the hospital with no weakness. Two weeks later, the follow-up electrophysiology study was normal. Here, we described an unusual case of recurrent GBS associated with COVID-19. Both episodes of GBS in our patient were triggered by COVID-19. The patients with recurrent GBS show similar signs and symptoms during every episode despite having different types of symptoms of a preceding infection.² In our patient, signs and symptoms were similar in both episodes, only the first episode was more severe. Recurrent GBS is rare, and usually, patients with recurrences have been adults. Recurrent GBS patients represent 6% of patients with GBS.³ Miller Fisher syndrome is a variant of GBS. Recurrent Miller Fisher syndrome has been reported in children.⁴ The distinction between recurrent GBS and chronic inflammatory demyelinating polyneuropathy is important since the treatments are different.⁵ Our patient had returned to normal strength, viral triggers, areflexia with weakness in extremities and supportive electrodiagnostic results. These findings supported that our patient was diagnosed recurrent GBS. In conclusion, we would like to draw attention to the fact that patients with GBS associated with COVID-19 may also have a GBS episode if they get re-infected with COVID-19 subsequently. Written informed consent to publication has been obtained from the parents on behalf of the patient.

TABLE 1.

Pertinent Laboratory Findings for Each Guillain–Barré Syndrome Episode

	2020	2022
WBC count, ×103/μL	9.96	8.20
Neutrophil, ×103/μL	8.33	6.19
Lymphocyte, ×103/μL	0.95	0.94
Platelets, ×103/μL	359	292
Hemoglobin, g/dL	13.5	13.5
C-reactive protein, mg/L	3	5
Pro-calcitonin, ng/mL	0.16	0.15
Urea (mg/dL)	33	18.7
Creatinine (mg/dL)	0.37	0.54
AST (U/L)	31	24
ALT (U/L)	20	18
CK (U/L)	50	154
LDH (U/L)	279	361
Serum glucose (mg/dL)	99	108
CSF protein (mg/dL)	51	25
CSF glucose (mg/dL)	78	61
CSF cell count (per mm3)	-	-
Oligoclonal band	Negative	Negative
Respiratory viral panel	SARS-CoV-2 positive	SARS-CoV-2 positive

ALT, alanine aminotransferase; AST, aspartate aminotransferase; CK, creatine-kinase; CSF indicates cerebrospinal fluid; LDH, lactate dehydrogenase; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; WBC, white blood cell.