TOPIC: Respiratory Care
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: The delineation of COVID-19 extrapulmonary manifestations and sequelae continues to change. Multiorgan involvement is well established however neurologic manifestations remain varied. One manifestation is immunologic involvement of the peripheral nervous system, resulting in chronic inflammatory demyelinating disease such as Guillain Barre Syndrome. Most commonly triggered by a molecular mimicry to a preceding infection, GBS usually starts in the distal lower extremity and ascends causing symptoms and signs of a lower motor neuron lesion. An unusual variant of GBS that primarily affects the cranial nerve fibers is Miller Fisher Syndrome. To date, GBS is not widely reported in association with COVID-19.
      CASE PRESENTATION: This is a case of a 59 year old Male with past medical history of Hypertension and recent COVID-19 infection three weeks prior to admission, treated with Azithromycin as an outpatient, who presented with bilateral lower extremity weakness. The weakness was sudden and associated with bilateral hand numbness, tingling and paresthesia. He denied fevers, chills, nausea, vomiting, headache, visual disturbance, loss of consciousness, chest pain, palpitations, urinary or bowel dysfunction. There was no respiratory distress on admission. Neurological exam revealed bilateral lower extremity decreased strength and ataxia. Cerebrospinal fluid analysis was obtained and the patient was empirically started on Intravenous Immunoglobulin. CSF total protein was found to be 93 mg/dL and cell count was 2 cells/uL. MRI brain and spine showed no anatomic abnormalities and CSF and serologic testing for infectious causes were negative. Over the hospitalization the patient developed progressive facial diplegia and worsening bulbar involvement. There was decreasing Forced Vital Capacity and worsening hypercapnia. Patient was transferred to ICU placed on BIPAP with a low threshold for intubation and monitored closely. Serial FVC testing was done to monitor respiratory status. He completed a 5 day course of IVIG with symptom improvement. His disease progression stabilized and slowly he began to recover his strength with the aid of extensive physical therapy.
      DISCUSSION: Our patient fits common characteristics including male gender predominance and common COVID-19 symptomatology (1). As in other reported cases, there was a noted CSF albuminocytologic dissociation and a negative test for antiganglioside antibodies, which occur in 76% and 88% respectively. Most cases in the literature report the classical sensorimotor demyelinating form of GBS (2).
      CONCLUSIONS: This case illustrates a rare variant of GBS primarily affecting the cranial nerves distribution, including cardinal signs of MFS despite a negative ganglioside antibody panel. It is imperative to have an early clinical suspicion to provide immediate intervention and avoid potentially fatal outcomes such as neuromuscular respiratory failure.
      REFERENCE #1: Caress JB, Castoro RJ, Simmons Z, Scelsa SN, Lewis RA, Ahlawat A, Narayanaswami P. COVID-19-associated Guillain-Barré syndrome: The early pandemic experience. Muscle Nerve. 2020 Oct;62(4):485-491. doi: 10.1002/mus.27024. Epub 2020 Aug 11. PMID: 32678460; PMCID: PMC7405390.
      REFERENCE #2: Uncini A, Vallat JM, Jacobs BC. Guillain-Barré syndrome in SARS-CoV-2 infection: an instant systematic review of the first six months of pandemic. J Neurol Neurosurg Psychiatry. 2020 Oct;91(10):1105-1110. doi: 10.1136/jnnp-2020-324491. Epub 2020 Aug 27. PMID: 32855289.
      DISCLOSURES: No relevant relationships by Orlirio Corrales, source=Web Response
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