Guillain-Barre syndrome related to COVID-19: muscle and nerve biopsy findings
Keywords:COVID-19, Peripheral nervous system, biopsies, Guillain-Barré Syndrome
Background: The involvement of the peripheral nervous system (PNS) in COVID-19 is rare and, to date, morphological aspects from muscle and nerve biopsies have not been reported. Here, we describe a case of Guillain-Barré Syndrome (GBS) related to COVID-19 and demonstrate findings from peripheral nerve and skeletal muscle biopsies.
A 79-year-old man presented with progressive weakness in both legs over one-week, evolving to both arms and urinary retention within 6 days. Four days earlier, he had a cough, febrile sensation and mild respiratory discomfort. On admission, his was afebrile, and without respiratory distress. A neurological examination disclosed asymmetric proximal weakness, diminished reflexes and no sensitive abnormalities. Three days later, the patient presented with bilateral facial weakness and proximal muscle strength worsened. Deep tendon reflexes and plantar responses were absent. Both superficial and profound sensitivity were decreased. From this point, oxygen saturation worsened, and the patient was placed on mechanical ventilation. CSF testing revealed one cell and protein 185 mg/dl. A chest CT showed the presence of ground-glass opacities and RT-PCR for SARS-CoV-2 was positive. The muscle biopsy revealed moderate neuromyopathic findings with positive expression for MHC-class I, C5b9, CD8 and CD68. The nerve biopsy showed inflammatory infiltrates predominantly with endoneurial compound formed by CD45 and CD68. The patient was treated with Oseltamivir for 9 days followed by IVIG for 5 days and died three days later of septic shock.
Discussion: This is the first documented case of GBS associated with COVID-19 with a muscle and nerve anatomopathological study. A systematic review about neurological complications caused by COVID-19 described 11 patients with GBS. The morphological features reported in our patient showed signs of involvement of the immune system, suggesting that direct viral invasion could have played a role in the pathogenesis of peripheral nerve injury.
Hereafter, further research will be necessary to understand the triggers for these cells migrating into the peripheral nerve.
Ahmad I, Rathore FA. Neurological manifestations and complications of COVID-19: A literature review. J Clin Neurosci. 2020; S0967-5868(20)31078-X. doi: 10.1016/j.jocn.2020.05.017
Suh J, Mukerji SS, Collens SI, Padera RF Jr, Pinkus GS, Amato AA, Solomon IH. Skeletal Muscle and Peripheral Nerve Histopathology in COVID-19. Neurology. 2021 Aug 24;97(8):e849-e858. doi: 10.1212/WNL.0000000000012344. Epub 2021 Jun 7. PMID: 34099523.
Aschman T, Schneider J, Greuel S, Meinhardt J, Streit S, Goebel HH, Büttnerova I, Elezkurtaj S, Scheibe F, Radke J, Meisel C, Drosten C, Radbruch H, Heppner FL, Corman VM, Stenzel W. Association Between SARS-CoV-2 Infection and Immune-Mediated Myopathy in Patients Who Have Died. JAMA Neurol. 2021 Aug 1;78(8):948-960. doi: 10.1001/jamaneurol.2021.2004. PMID: 34115106.
Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hospitalized Patients with Coronavirus Disease 2019 in Wuhan, China [published online ahead of print, 2020 Apr 10]. JAMA Neurol. 2020; e201127. doi:10.1001/jamaneurol.2020.1127
Munhoz RP, Pedroso JP, Nascimento FA et al. Neurological complications in patients with SARS-CoV-2 infection: a systematic review. Arq Neuropsiquiatr: 2020; 1-11; https://doi.org/10.1590/0004-282X20200051
Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun. 2020; 109:102433. doi: 10.1016/j.jaut.2020.102433.
Iwasaki A, Medzhitov R. Control of adaptive immunity by the innate immune system. Nat Immunol. 2015;16(4):343-353. doi:10.1038/ni.3123
Robinson-Papp J, Simpson DM. Neuromuscular diseases associated with HIV-1 infection. Muscle Nerve. 2009;40(6):1043-1053. Doi:10.1002/mus.21465.
Copyright (c) 2021 Souza DCL, Guimarães RB, Carvalho AAS
This work is licensed under a Creative Commons Attribution 4.0 International License.